The impact on quality of life of dialysis patients with renal insufficiency.

PubMed

Dąbrowska-Bender, Marta; Dykowska, Grażyna; Żuk, Wioletta; Milewska, Magdalena; Staniszewska, Anna

2018-01-01

The aim of the study was the subjective assessment of the quality of life (QoL) of 140 patients treated with dialysis (peritoneal dialysis and hemodialysis). Chronic kidney disease and the methods of its treatment play an important part in shaping the QoL of patients receiving dialysis. As a result, kidney failure causes many limitations in patients' physical, mental, and social activities. The instrument to measure the QoL was the authors' own questionnaire made on the basis of Kidney Disease and Quality of Life Short Form version 1.2 (KDQOL - SF 1.2) and their selection of areas influencing the perceived QoL of chronically ill patients. The research showed that patients receiving peritoneal dialysis assessed their QoL in its different dimensions as much higher than patients receiving hemodialysis. The parameter having the biggest negative impact on the QoL of patients receiving hemodialysis was an impeded possibility to continue work or studies and a change of life plans. The will to live was more highly assessed by patients receiving peritoneal dialysis as compared to patients receiving hemodialysis. In order to improve the functioning of hemodialysis patients in a manner most similar to healthy persons, the renal replacement therapy should consider patients' individual needs and expectations, ie, guarantee flexible hours of work or study and of receiving dialysis. In addition, patients treated with hemodialysis should receive psychological care, in particular those demonstrating emotional problems, in order to achieve better results in therapy and improve their QoL.

The impact on quality of life of dialysis patients with renal insufficiency

PubMed Central

Dąbrowska-Bender, Marta; Dykowska, Grażyna; Żuk, Wioletta; Milewska, Magdalena; Staniszewska, Anna

2018-01-01

Aim The aim of the study was the subjective assessment of the quality of life (QoL) of 140 patients treated with dialysis (peritoneal dialysis and hemodialysis). Background Chronic kidney disease and the methods of its treatment play an important part in shaping the QoL of patients receiving dialysis. As a result, kidney failure causes many limitations in patients’ physical, mental, and social activities. Methods The instrument to measure the QoL was the authors’ own questionnaire made on the basis of Kidney Disease and Quality of Life Short Form version 1.2 (KDQOL – SF 1.2) and their selection of areas influencing the perceived QoL of chronically ill patients. Results The research showed that patients receiving peritoneal dialysis assessed their QoL in its different dimensions as much higher than patients receiving hemodialysis. The parameter having the biggest negative impact on the QoL of patients receiving hemodialysis was an impeded possibility to continue work or studies and a change of life plans. The will to live was more highly assessed by patients receiving peritoneal dialysis as compared to patients receiving hemodialysis. Conclusion In order to improve the functioning of hemodialysis patients in a manner most similar to healthy persons, the renal replacement therapy should consider patients’ individual needs and expectations, ie, guarantee flexible hours of work or study and of receiving dialysis. In addition, patients treated with hemodialysis should receive psychological care, in particular those demonstrating emotional problems, in order to achieve better results in therapy and improve their QoL. PMID:29720873

Consolidation in the Dialysis Industry, Patient Choice, and Local Market Competition

PubMed Central

Zheng, Yuanchao; Winkelmayer, Wolfgang C.; Bhattacharya, Jay; Chertow, Glenn M.

2017-01-01

The Medicare program insures >80% of patients with ESRD in the United States. An emphasis on reducing outpatient dialysis costs has motivated consolidation among dialysis providers, with two for-profit corporations now providing dialysis for >70% of patients. It is unknown whether industry consolidation has affected patients’ ability to choose among competing dialysis providers. We identified patients receiving in-center hemodialysis at the start of 2001 and 2011 from the national ESRD registry and ascertained dialysis facility ownership. For each hospital service area, we determined the maximum distance within which 90% of patients traveled to receive dialysis in 2001. We compared the numbers of competing dialysis providers within that same distance between 2001 and 2011. Additionally, we examined the Herfindahl–Hirschman Index, a metric of market concentration ranging from near zero (perfect competition) to one (monopoly) for each hospital service area. Between 2001 and 2011, the number of different uniquely owned competing providers decreased 8%. However, increased facility entry into markets to meet rising demand for care offset the effect of provider consolidation on the number of choices available to patients. The number of dialysis facilities in the United States increased by 54%, and patients experienced an average 10% increase in the number of competing proximate facilities from which they could choose to receive dialysis (P<0.001). Local markets were highly concentrated in both 2001 and 2011 (mean Herfindahl–Hirschman Index =0.46; SD=0.2 for both years), but overall market concentration did not materially change. In summary, a decade of consolidation in the United States dialysis industry did not (on average) limit patient choice or result in more concentrated local markets. However, because dialysis markets remained highly concentrated, it will be important to understand whether market competition affects prices paid by private insurers, access to

Associations of health literacy with dialysis adherence and health resource utilization in patients receiving maintenance hemodialysis.

PubMed

Green, Jamie A; Mor, Maria K; Shields, Anne Marie; Sevick, Mary Ann; Arnold, Robert M; Palevsky, Paul M; Fine, Michael J; Weisbord, Steven D

2013-07-01

Although limited health literacy is common in hemodialysis patients, its effects on clinical outcomes are not well understood. Observational study. 260 maintenance hemodialysis patients enrolled in a randomized clinical trial of symptom management strategies from January 2009 through April 2011. Limited health literacy. Dialysis adherence (missed and abbreviated treatments) and health resource utilization (emergency department visits and end-stage renal disease [ESRD]-related hospitalizations). We assessed health literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM) and used negative binomial regression to analyze the independent associations of limited health literacy with dialysis adherence and health resource utilization over 12-24 months. 41 of 260 (16%) patients showed limited health literacy (REALM score, ≤60). There were 1,152 missed treatments, 5,127 abbreviated treatments, 552 emergency department visits, and 463 ESRD-related hospitalizations. Limited health literacy was associated independently with an increased incidence of missed dialysis treatments (missed, 0.6% vs 0.3%; adjusted incidence rate ratio [IRR], 2.14; 95% CI, 1.10-4.17), emergency department visits (annual visits, 1.7 vs 1.0; adjusted IRR, 1.37; 95% CI, 1.01-1.86), and hospitalizations related to ESRD (annual hospitalizations, 0.9 vs 0.5; adjusted IRR, 1.55; 95% CI, 1.03-2.34). Generalizability and potential for residual confounding. Patients receiving maintenance hemodialysis who have limited health literacy are more likely to miss dialysis treatments, use emergency care, and be hospitalized related to their kidney disease. These findings have important clinical practice and cost implications. Copyright © 2013 National Kidney Foundation, Inc. All rights reserved.

Can dialysis patients be accurately identified using healthcare claims data?

PubMed

Taneja, Charu; Berger, Ariel; Inglese, Gary W; Lamerato, Lois; Sloand, James A; Wolff, Greg G; Sheehan, Michael; Oster, Gerry

2014-01-01

While health insurance claims data are often used to estimate the costs of renal replacement therapy in patients with end-stage renal disease (ESRD), the accuracy of methods used to identify patients receiving dialysis - especially peritoneal dialysis (PD) and hemodialysis (HD) - in these data is unknown. The study population consisted of all persons aged 18 - 63 years in a large US integrated health plan with ESRD and dialysis-related billing codes (i.e., diagnosis, procedures) on healthcare encounters between January 1, 2005, and December 31, 2008. Using billing codes for all healthcare encounters within 30 days of each patient's first dialysis-related claim ("index encounter"), we attempted to designate each study subject as either a "PD patient" or "HD patient." Using alternative windows of ± 30 days, ± 90 days, and ± 180 days around the index encounter, we reviewed patients' medical records to determine the dialysis modality actually received. We calculated the positive predictive value (PPV) for each dialysis-related billing code, using information in patients' medical records as the "gold standard." We identified a total of 233 patients with evidence of ESRD and receipt of dialysis in healthcare claims data. Based on examination of billing codes, 43 and 173 study subjects were designated PD patients and HD patients, respectively (14 patients had evidence of PD and HD, and modality could not be ascertained for 31 patients). The PPV of codes used to identify PD patients was low based on a ± 30-day medical record review window (34.9%), and increased with use of ± 90-day and ± 180-day windows (both 67.4%). The PPV for codes used to identify HD patients was uniformly high - 86.7% based on ± 30-day review, 90.8% based on ± 90-day review, and 93.1% based on ± 180-day review. While HD patients could be accurately identified using billing codes in healthcare claims data, case identification was much more problematic for patients receiving PD. Copyright �

Consolidation in the Dialysis Industry, Patient Choice, and Local Market Competition.

PubMed

Erickson, Kevin F; Zheng, Yuanchao; Winkelmayer, Wolfgang C; Ho, Vivian; Bhattacharya, Jay; Chertow, Glenn M

2017-03-07

The Medicare program insures >80% of patients with ESRD in the United States. An emphasis on reducing outpatient dialysis costs has motivated consolidation among dialysis providers, with two for-profit corporations now providing dialysis for >70% of patients. It is unknown whether industry consolidation has affected patients' ability to choose among competing dialysis providers. We identified patients receiving in-center hemodialysis at the start of 2001 and 2011 from the national ESRD registry and ascertained dialysis facility ownership. For each hospital service area, we determined the maximum distance within which 90% of patients traveled to receive dialysis in 2001. We compared the numbers of competing dialysis providers within that same distance between 2001 and 2011. Additionally, we examined the Herfindahl-Hirschman Index, a metric of market concentration ranging from near zero (perfect competition) to one (monopoly) for each hospital service area. Between 2001 and 2011, the number of different uniquely owned competing providers decreased 8%. However, increased facility entry into markets to meet rising demand for care offset the effect of provider consolidation on the number of choices available to patients. The number of dialysis facilities in the United States increased by 54%, and patients experienced an average 10% increase in the number of competing proximate facilities from which they could choose to receive dialysis ( P <0.001). Local markets were highly concentrated in both 2001 and 2011 (mean Herfindahl-Hirschman Index =0.46; SD=0.2 for both years), but overall market concentration did not materially change. In summary, a decade of consolidation in the United States dialysis industry did not (on average) limit patient choice or result in more concentrated local markets. However, because dialysis markets remained highly concentrated, it will be important to understand whether market competition affects prices paid by private insurers, access to

Combining structured and unstructured data to identify a cohort of ICU patients who received dialysis

PubMed Central

Abhyankar, Swapna; Demner-Fushman, Dina; Callaghan, Fiona M; McDonald, Clement J

2014-01-01

Objective To develop a generalizable method for identifying patient cohorts from electronic health record (EHR) data—in this case, patients having dialysis—that uses simple information retrieval (IR) tools. Methods We used the coded data and clinical notes from the 24 506 adult patients in the Multiparameter Intelligent Monitoring in Intensive Care database to identify patients who had dialysis. We used SQL queries to search the procedure, diagnosis, and coded nursing observations tables based on ICD-9 and local codes. We used a domain-specific search engine to find clinical notes containing terms related to dialysis. We manually validated the available records for a 10% random sample of patients who potentially had dialysis and a random sample of 200 patients who were not identified as having dialysis based on any of the sources. Results We identified 1844 patients that potentially had dialysis: 1481 from the three coded sources and 1624 from the clinical notes. Precision for identifying dialysis patients based on available data was estimated to be 78.4% (95% CI 71.9% to 84.2%) and recall was 100% (95% CI 86% to 100%). Conclusions Combining structured EHR data with information from clinical notes using simple queries increases the utility of both types of data for cohort identification. Patients identified by more than one source are more likely to meet the inclusion criteria; however, including patients found in any of the sources increases recall. This method is attractive because it is available to researchers with access to EHR data and off-the-shelf IR tools. PMID:24384230

Risk of pulmonary embolism in patients with end-stage renal disease receiving long-term dialysis.

PubMed

Wang, I-Kuan; Shen, Te-Chun; Muo, Chih-Hsin; Yen, Tzung-Hai; Sung, Fung-Chang

2017-08-01

This study compared the pulmonary embolism (PE) risks between Asian dialysis patients and a comparison cohort without clinical kidney disease. From the National Health Insurance claims data of Taiwan, we identified 106 231 newly diagnosed end-stage renal disease patients undergoing dialysis in 1998-2010 and randomly selected 106 231 comparison subjects, frequency matched by age, sex and the index year. We further selected 7430 peritoneal dialysis (PD) patients and 7340 propensity score-matched hemodialysis (HD) patients. Incidence rates and hazard ratios (HRs) of PE and odds ratio (OR) of subsequent 30-day deaths from PE were evaluated among study cohorts by the end of 2011. The overall incident PE was nearly 3-fold greater in dialysis patients than in the comparison cohort (0.92 versus 0.33 per 1000 person-years), with an adjusted HR of 2.02 [95% confidence interval (CI) = 1.63-2.50]. The PE incidence was greater in the propensity score-matched HD patients, than in PD patients with an adjusted HR of 2.30 (95% CI = 1.23-4.29). There was a greater PE risk for central venous catheter users than non-users among HD patients (1.83 versus 0.75 per 1000 person-years). The 30-day mortality from PE was higher in dialysis patients than in the comparison cohort (16.5 versus 9.77%) with an adjusted OR of 2.56 (95% CI = 1.32-4.95). Dialysis patients are at a nearly 2-fold increased hazard of developing PE and are at greater risk of fatality from PE compared with those without clinical kidney disease. This study also shows a higher PE risk in HD patients than in PD patients. © The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

The clinical and economic burden of pneumonia in patients enrolled in Medicare receiving dialysis: a retrospective, observational cohort study.

PubMed

Sibbel, Scott; Sato, Reiko; Hunt, Abigail; Turenne, Wendy; Brunelli, Steven M

2016-12-12

End-stage renal disease (ESRD) patients receiving dialysis are at particular risk for infection. We assessed the clinical and economic burden of pneumonia in a population of Medicare-enrolled ESRD patients with respect to incidence and case fatality rates, rates of all-cause and cardiovascular hospitalization, and costs. Patients received dialysis between 01 January 2009 and 31 December 2011 and were enrolled in Medicare Parts A and B. Pneumonia episodes were identified from institutional and supplier claims. Patients were considered at-risk from first date of Medicare coverage and were censored upon transplant, withdrawal from dialysis, recovery of renal function, loss of Medicare benefits, or death. Linear mixed-effects models were used to assess hospitalization rates and costs over the 3 months prior to and 12 months following pneumonia episodes. The pneumonia incidence rate for the study period was 21.4 events/100 patient-years; the majority of episodes (90.1%) required inpatient treatment. The 30-day case fatality rate was 10.7%. Compared to month -3 prior to event, rates of all-cause and cardiovascular hospitalization were higher in the month of the pneumonia episode (IRR, 4.61 and 4.30). All-cause admission rates remained elevated through month 12; cardiovascular admission rates remained elevated through month 6. Mean per-patient per-month costs were $10,976 higher in the month of index episode compared to month -3, largely driven by increased inpatient costs, and remained elevated through end of 12-month follow-up. Pneumonia episodes are frequent among ESRD patients and result in hospitalizations and greater overall costs to Medicare over the following year.

Beta-blockers and cardiovascular outcomes in dialysis patients: a cohort study in Ontario, Canada.

PubMed

Kitchlu, Abhijat; Clemens, Kristin; Gomes, Tara; Hackam, Daniel G; Juurlink, David N; Mamdani, Muhammad; Manno, Michael; Oliver, Matthew J; Quinn, Robert R; Suri, Rita S; Wald, Ron; Yan, Andrew T; Garg, Amit X

2012-04-01

Beta-blockers may be cardioprotective in patients receiving chronic dialysis. We examined cardiovascular outcomes among incident dialysis patients receiving beta-blocker therapy. We conducted a retrospective cohort study employing linked healthcare databases in Ontario, Canada. We studied all consecutive chronic dialysis patients aged≥66 years who initiated dialysis between 1 July 1991 and 31 July 2007. Patients were divided into three groups according to new medication use after the initiation of chronic dialysis. The three groups were patients initiated on beta-blockers, calcium channel blockers and statins only. Patients in the beta-blocker and calcium channel blocker groups could also be concurrently receiving a statin. The primary outcome was time to a composite endpoint of death, myocardial infarction, stroke or coronary revascularization. There were a total of 1836 patients (504 beta-blocker, 570 calcium channel blocker and 762 statin-only users). Compared to statin-only use, beta-blocker use was not associated with improved cardiovascular outcomes [adjusted hazard ratio (aHR) 1.07, 95% confidence interval (CI) 0.92-1.23]. As expected, calcium channel blocker use was also not associated with improved cardiovascular outcomes (aHR 0.91, 95% CI 0.79-1.06). Among all subgroup analyses by beta-blocker attributes, only high-dose beta-blocker therapy was associated with better cardiovascular outcomes as compared to low-dose beta-blockers (aHR 0.50, 95% CI 0.29-0.88). We observed no beneficial effect of beta-blocker use among patients receiving chronic dialysis relative to our comparator groups. Given current uncertainty around the cardioprotective benefits of beta-blockers in patients receiving dialysis, a large randomized clinical trial is warranted.

Health-related quality of life and all-cause mortality in patients with diabetes on dialysis

PubMed Central

2012-01-01

Background This study tests the hypotheses that health-related quality of life (HRQOL) in prevalent dialysis patients with diabetes is lower than in dialysis patients without diabetes, and is at least as poor as diabetic patients with another severe complication, i.e. foot ulcers. This study also explores the mortality risk associated with diabetes in dialysis patients. Methods HRQOL was assessed using the Short Form-36 Health Survey (SF-36), in a cross-sectional study of 301 prevalent dialysis patients (26% with diabetes), and compared with diabetic patients not on dialysis (n = 221), diabetic patients with foot ulcers (n = 127), and a sample of the general population (n = 5903). Mortality risk was assessed using a Kaplan-Meier plot and Cox proportional hazards analysis. Results Self-assessed vitality, general and mental health, and physical function were significantly lower in dialysis patients with diabetes than in those without. Vitality (p = 0.011) and general health (p <0.001) was impaired in diabetic patients receiving dialysis compared to diabetic patients with foot ulcers, but other subscales did not differ. Diabetes was a significant predictor for mortality in dialysis patients, with a hazard ratio (HR) of 1.6 (95% CI 1.0-2.5) after adjustment for age, dialysis vintage and coronary artery disease. Mental aspects of HRQOL were an independent predictor of mortality in diabetic patients receiving dialysis after adjusting for age and dialysis vintage (HR 2.2, 95% CI 1.0-5.0). Conclusions Physical aspects of HRQOL were perceived very low in dialysis patients with diabetes, and lower than in other dialysis patients and diabetic patients without dialysis. Mental aspects predicted mortality in dialysis patients with diabetes. Increased awareness and measures to assist physical function impairment may be particularly important in diabetes patients on dialysis. PMID:22863310

Hospitalization rates among dialysis patients during Hurricane Katrina.

PubMed

Howard, David; Zhang, Rebecca; Huang, Yijian; Kutner, Nancy

2012-08-01

Dialysis centers struggled to maintain continuity of care for dialysis patients during and immediately following Hurricane Katrina's landfall on the US Gulf Coast in August 2005. However, the impact on patient health and service use is unclear. The impact of Hurricane Katrina on hospitalization rates among dialysis patients was estimated. Data from the United States Renal Data System were used to identify patients receiving dialysis from January 1, 2001 through August 29, 2005 at clinics that experienced service disruptions during Hurricane Katrina. A repeated events duration model was used with a time-varying Hurricane Katrina indicator to estimate trends in hospitalization rates. Trends were estimated separately by cause: surgical hospitalizations, medical, non-renal-related hospitalizations, and renal-related hospitalizations. The rate ratio for all-cause hospitalization associated with the time-varying Hurricane Katrina indicator was 1.16 (95% CI, 1.05-1.29; P = .004). The ratios for cause-specific hospitalization were: surgery, 0.84 (95% CI, 0.68-1.04; P = .11); renal-related admissions, 2.53 (95% CI, 2.09-3.06); P < .001), and medical non-renal related, 1.04 (95% CI, 0.89-1.20; P = .63). The estimated number of excess renal-related hospital admissions attributable to Katrina was 140, representing approximately three percent of dialysis patients at the affected clinics. Hospitalization rates among dialysis patients increased in the month following the Hurricane Katrina landfall, suggesting that providers and patients were not adequately prepared for large-scale disasters.

Response to inadequate dialysis in chronic peritoneal dialysis patients. Results from the 2000 Centers for Medicare and Medicaid (CMS) ESRD Peritoneal Dialysis Clinical Performance Measures (PD-CPM) Project.

PubMed

Rocco, Michael V; Frankenfield, Diane L; Prowant, Barbara; Frederick, Pamela; Flanigan, Michael J

2003-04-01

It is not known if patient prescriptions are being changed if patients are receiving an inadequate dose of peritoneal dialysis. Data from the 2000 Centers for Medicare and Medicaid were used to obtain data on dialysis adequacy and dialysis prescriptions. A total of 359 of 1,268 (28%) adult peritoneal dialysis patients had a total weekly Kt/V urea (twKt/V) less than 2.0 and 436 of 1,245 (35%) patients had a total weekly creatinine clearance (twCrCl) less than 60 L/wk/1.73 m2, defined as "inadequate dialysis." Among chronic ambulatory peritoneal dialysis (CAPD) patients, 81 of 188 (43%) patients had inadequate dialysis and a change in the peritoneal dialysis prescription within 6 months of the initial adequacy value. Among cycler patients, 106 of 197 (54%) patients had inadequate dialysis and a change in the prescription. Thirty-six of 46 (78%) CAPD patients and 48 of 56 (86%) cycler patients had an improvement in twKt/V after the prescription was revised. Thirty-two of 42 (76%) CAPD patients and 45 of 57 (79%) cycler patients had an improvement in twCrCl after the prescription was changed. For these patients, twKt/V increased from 1.6 +/- 0.3 to 2.1 +/- 0.5, with an increase in the peritoneal Kt/V urea from 1.5 +/- 0.3 to 1.9 +/- 0.4. Similarly, twCrCl increased from 46.3 +/- 7.5 to 59.1 +/- 10.6 L/wk/1.73 m2 with an increase in the peritoneal CrCl dose from 42.0 +/- 9.1 to 52.7 +/- 9.9 L/wk/1.73 m2. About half of peritoneal dialysis patients with inadequate dialysis did not have a prescription change and could benefit from modifications in their dialysis prescription.

Employment of patients receiving maintenance dialysis and after kidney transplant: a cross-sectional study from Finland.

PubMed

Helanterä, Ilkka; Haapio, Mikko; Koskinen, Petri; Grönhagen-Riska, Carola; Finne, Patrik

2012-05-01

Associations between mode of renal replacement therapy and employment rate have not been well characterized. Cross-sectional registry analysis. The employment status of all prevalent 15- to 64-year-old dialysis and kidney transplant patients in Finland at the end of 2007 (N = 2,637) was analyzed by combining data from the Finnish Registry for Kidney Diseases with individual-level employment statistics of the Finnish government. Prevalence rate ratios (PRRs) of employment according to treatment modality with adjustment for age, sex, cause of end-stage renal disease (ESRD), duration of ESRD, and comorbid conditions were estimated using Cox regression with a constant time at risk. Employment status of patients on dialysis therapy or after transplant. Clinical data were collected from the Finnish Registry for Kidney Diseases, and employment data were acquired from Statistics Finland. 19% of hemodialysis patients, 31% of peritoneal dialysis patients, and 40% of patients with a functioning transplant were employed; the overall employment rate for the Finnish population aged 15-64 years is 67%. Home hemodialysis patients and those treated with automated peritoneal dialysis had employment rates of 39% and 44%, respectively. In adjusted analysis, patients on home hemodialysis therapy (PRR, 1.87), on automated peritoneal dialysis therapy (PRR, 2.14), or with a kidney transplant (PRR, 2.30) had higher probabilities of employment than in-center hemodialysis patients. Patients with type 1 or 2 diabetes as the cause of ESRD had the lowest probability of employment (PRR, 0.48-0.60 compared with glomerulonephritis). Patients aged 25-54 years more frequently were employed than those younger than 25 or older than 54 years. Sex did not predict employment. For transplant recipients, longer time since transplant was associated with higher employment in addition to the mentioned factors. Cross-sectional design. Employment rate of home dialysis patients was similar to that of transplant

Evaluating Infection Prevention Strategies in Out-Patient Dialysis Units Using Agent-Based Modeling.

PubMed

Wares, Joanna R; Lawson, Barry; Shemin, Douglas; D'Agata, Erika M C

2016-01-01

Patients receiving chronic hemodialysis (CHD) are among the most vulnerable to infections caused by multidrug-resistant organisms (MDRO), which are associated with high rates of morbidity and mortality. Current guidelines to reduce transmission of MDRO in the out-patient dialysis unit are targeted at patients considered to be high-risk for transmitting these organisms: those with infected skin wounds not contained by a dressing, or those with fecal incontinence or uncontrolled diarrhea. Here, we hypothesize that targeting patients receiving antimicrobial treatment would more effectively reduce transmission and acquisition of MDRO. We also hypothesize that environmental contamination plays a role in the dissemination of MDRO in the dialysis unit. To address our hypotheses, we built an agent-based model to simulate different treatment strategies in a dialysis unit. Our results suggest that reducing antimicrobial treatment, either by reducing the number of patients receiving treatment or by reducing the duration of the treatment, markedly reduces overall colonization rates and also the levels of environmental contamination in the dialysis unit. Our results also suggest that improving the environmental decontamination efficacy between patient dialysis treatments is an effective method for reducing colonization and contamination rates. These findings have important implications for the development and implementation of future infection prevention strategies.

Recent Peritonitis Associates with Mortality among Patients Treated with Peritoneal Dialysis

PubMed Central

Kemp, Anna; Clayton, Philip; Lim, Wai; Badve, Sunil V.; Hawley, Carmel M.; McDonald, Stephen P.; Wiggins, Kathryn J.; Bannister, Kym M.; Brown, Fiona G.; Johnson, David W.

2012-01-01

Peritonitis is a major complication of peritoneal dialysis, but the relationship between peritonitis and mortality among these patients is not well understood. In this case-crossover study, we included the 1316 patients who received peritoneal dialysis in Australia and New Zealand from May 2004 through December 2009 and either died on peritoneal dialysis or within 30 days of transfer to hemodialysis. Each patient served as his or her own control. The mean age was 70 years, and the mean time receiving peritoneal dialysis was 3 years. In total, there were 1446 reported episodes of peritonitis with 27% of patients having ≥2 episodes. Compared with the rest of the year, there were significantly increased odds of peritonitis during the 120 days before death, although the magnitude of this association was much greater during the 30 days before death. Compared with a 30-day window 6 months before death, the odds for peritonitis was six-fold higher during the 30 days immediately before death (odds ratio, 6.2; 95% confidence interval, 4.4–8.7). In conclusion, peritonitis significantly associates with mortality in peritoneal dialysis patients. The increased odds extend up to 120 days after an episode of peritonitis but the magnitude is greater during the initial 30 days. PMID:22626818

Likelihood of Starting Dialysis after Incident Fistula Creation

PubMed Central

Quinn, Robert R.; Garg, Amit X.; Kim, S. Joseph; Wald, Ron; Paterson, J. Michael

2012-01-01

Summary Background and objectives Guidelines promote early fistula creation to avoid central venous catheter use. This practice may lead to fistula creations in patients who never receive dialysis. The objective of this study was to estimate the risk of fistula nonuse with long-term follow-up. Design, setting, participants, & measurements Administrative health data identified 1929 predialysis adults who had their first fistula creation between April of 2002 and March of 2006. Patients were followed for a minimum of 2 years or until they began dialysis, received a kidney transplant, or died. Results The median follow-up times in patients who started dialysis, died without receiving dialysis, and remained in predialysis were 6.1, 11.5, and 38.7 months, respectively. Eighty-one percent of patients initiated dialysis; 9% of patients died without receiving dialysis, and 10% of patients remained predialysis. Forty percent of patients had their first fistula creation 3–12 months before initiating dialysis (the recommended window). Thirty percent were created within 90 days of starting dialysis; 30% were created more than 1 year before starting dialysis, and 10% were created more than 2 years before starting dialysis. Older patients, females, and patients with less comorbidity were not as likely to initiate dialysis after incident fistula creation. Conclusions Most patients who underwent fistula creation before starting dialysis eventually received dialysis with extended follow-up, but the risk was significantly modified by age, sex, and comorbidity. Many patients had fistula creations earlier or later than recommended. PMID:22344512

Total hip arthroplasty in chronic dialysis patients in the United States.

PubMed

Abbott, Kevin C; Bucci, Jay R; Agodoa, Lawrence Y

2003-01-01

The national incidence of and factors associated with total hip arthroplasty (THA) in chronic dialysis patients has never been reported. We therefore performed an historical cohort study of 375,857 chronic dialysis patients listed in the 2000 United States Renal Data System between 1 April 1995 and 31 December 1999 and followed-up until 14 May 2000. Primary outcomes were associations with hospitalizations for a primary discharge code of THA (ICD9 procedure code 81.51x) after initiation of dialysis. Dialysis patients had a cumulative incidence of THA of 35 episodes/10,000 person-years, compared to 5.3/10,000 in the general population. The leading indication for THA was osteoarthritis of the hip and pelvis (58% of cases). However, the strongest risk factor for THA in dialysis patients was end-stage renal disease (ESRD) due to systemic lupus erythematosus (SLE, adjusted rate ratio (ARR), 6.80, 95% CI 4.62-10.03, in whom avascular necrosis of the hip was the most common indication, 68.4%). The database did not include information on use of corticosteroids. Diabetic recipients were significantly less likely to receive THA, as were males, and African Americans. Mortality after THA was 0.25% at thirty days and 30% at three years, not significantly different from the expected mortality of dialysis, adjusted for comorbidity. The most common indication for THA in dialysis patients is osteoarthritis of the hip, similar to the general population. Patients with SLE are more likely to receive THA which is well tolerated and not associated with increased mortality in this population, perhaps reflecting selection bias due to appropriate screening for this elective procedure.

Adherence of pediatric patients to automated peritoneal dialysis.

PubMed

Chua, Annabelle N; Warady, Bradley A

2011-05-01

Little information is available on adherence to a home automated peritoneal dialysis (APD) prescription for children with end-stage renal disease. We have therefore retrospectively reviewed HomeChoice PRO Card data from patients <21 years of age who received home APD. Adherence was characterized as occurring ≥ 95%, 90-94%, or <90% of time by dividing the frequency of each of four measured prescription variables (sessions/month, duration of each session, number of cycles/session, volume of dialysate/session) by the prescribed frequency and multiplying by 100. The relationship between treatment adherence and patient age, gender, race and if the patient had received training, respectively, was assessed. Of the 51 patients (57% male), with a mean age at peritoneal dialysis (PD) onset of 11.8 ± 5.3 years, 28 (55%) were adherent for all variables. No difference in mean age or if patients were trained existed between the two groups. Males were more likely to be non-adherent (p = 0.026) as were African Americans (p = 0.048). The majority of patients were adherent to duration (96%) and number of cycles (92%), whereas non-adherence was more common with number of sessions (82%) and dialysate volume (78%). In conclusion, 45% of the pediatric patients in our study cohort exhibited some non-adherence to their prescribed APD regimen, emphasizing the value of closely monitoring the performance of home dialysis in children.

Comparative Effectiveness of Renin-Angiotensin System Antagonists in Maintenance Dialysis Patients

PubMed Central

Shireman, Theresa I.; Mahnken, Jonathan D.; Phadnis, Milind A.; Ellerbeck, Edward F.; Wetmore, James B.

2017-01-01

Background/Aims Whether angiotensin converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) are differentially associated with reductions in cardiovascular events and mortality in patients receiving maintenance dialysis is uncertain. We compared outcomes between ACE and ARB users among hypertensive, maintenance dialysis patients. Methods National retrospective cohort study of hypertensive, Medicare-Medicaid eligible patients initiating chronic dialysis between 1/1/2000 to 12/31/2005. The exposure of interest was new use of either an ACEI or ARB. Outcomes were all-cause mortality (ACM) and combined cardiovascular hospitalization or death (CV-endpoint). Cox proportion hazards models were used to compare the effect of ACEI vs ARB use on ACM and, separately, CV-endpoint. Results ACM models were based on 3,555 ACEI and 1,442 ARB new users, while CV-endpoint models included 3,289 ACEI and 1,346 ARB new users. After statistical adjustments, ACEI users had higher hazard ratios for ACM (AHR = 1.22, 99% CI 1.05–1.42) and CV-endpoint (AHR = 1.12, 99% CI 0.99–1.27). Conclusions Patients initiating maintenance dialysis who received an ACEI faced an increased risk for mortality and a trend towards an increased risk for CV-endpoints when compared to patients who received an ARB. Validation of these results in a rigorous clinical trial is warranted. PMID:27871075

Comparative Effectiveness of Renin-Angiotensin System Antagonists in Maintenance Dialysis Patients.

PubMed

Shireman, Theresa I; Mahnken, Jonathan D; Phadnis, Milind A; Ellerbeck, Edward F; Wetmore, James B

2016-01-01

Whether angiotensin converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) are differentially associated with reductions in cardiovascular events and mortality in patients receiving maintenance dialysis is uncertain. We compared outcomes between ACE and ARB users among hypertensive, maintenance dialysis patients. National retrospective cohort study of hypertensive, Medicare-Medicaid eligible patients initiating chronic dialysis between 1/1/2000 to 12/31/2005. The exposure of interest was new use of either an ACEI or ARB. Outcomes were all-cause mortality (ACM) and combined cardiovascular hospitalization or death (CV-endpoint). Cox proportion hazards models were used to compare the effect of ACEI vs ARB use on ACM and, separately, CV-endpoint. ACM models were based on 3,555 ACEI and 1,442 ARB new users, while CV-endpoint models included 3,289 ACEI and 1,346 ARB new users. After statistical adjustments, ACEI users had higher hazard ratios for ACM (AHR = 1.22, 99% CI 1.05-1.42) and CV-endpoint (AHR = 1.12, 99% CI 0.99-1.27). Patients initiating maintenance dialysis who received an ACEI faced an increased risk for mortality and a trend towards an increased risk for CV-endpoints when compared to patients who received an ARB. Validation of these results in a rigorous clinical trial is warranted. © 2016 The Author(s) Published by S. Karger AG, Basel.

Understanding by Older Patients of Dialysis and Conservative Management for Chronic Kidney Failure

PubMed Central

Tonkin-Crine, Sarah; Okamoto, Ikumi; Leydon, Geraldine M.; Murtagh, Fliss E.M.; Farrington, Ken; Caskey, Fergus; Rayner, Hugh; Roderick, Paul

2015-01-01

Background Older adults with chronic kidney disease stage 5 may be offered a choice between dialysis and conservative management. Few studies have explored patients’ reasons for choosing conservative management and none have compared the views of those who have chosen different treatments across renal units. Study Design Qualitative study with semistructured interviews. Settings & Participants Patients 75 years or older recruited from 9 renal units. Units were chosen to reflect variation in the scale of delivery of conservative management. Methodology Semistructured interviews audiorecorded and transcribed verbatim. Analytical Approach Data were analyzed using thematic analysis. Results 42 interviews were completed, 4 to 6 per renal unit. Patients were sampled from those receiving dialysis, those preparing for dialysis, and those choosing conservative management. 14 patients in each group were interviewed. Patients who had chosen different treatments held varying beliefs about what dialysis could offer. The information that patients reported receiving from clinical staff differed between units. Patients from units with a more established conservative management pathway were more aware of conservative management, less often believed that dialysis would guarantee longevity, and more often had discussed the future with staff. Some patients receiving conservative management reported that they would have dialysis if they became unwell in the future, indicating the conditional nature of their decision. Limitations Recruitment of older adults with frailty and comorbid conditions was difficult and therefore transferability of findings to this population is limited. Conclusions Older adults with chronic kidney disease stage 5 who have chosen different treatment options have contrasting beliefs about the likely outcomes of dialysis for those who are influenced by information provided by renal units. Supporting renal staff in discussing conservative management as a valid

Body-image disturbance in adult dialysis patients.

PubMed

Partridge, Kate Alexandra; Robertson, Noelle

2011-01-01

An increasing number of individuals in the UK develop end-stage renal failure and receive dialysis to prolong their lives. Dialysis-users report elevated levels of psychological morbidity which are associated with poorer quality of life, adjustment to illness and increased mortality. Circumscribed evidence has also identified body-image (BI) changes occurring in dialysis-users which are already known to be associated with psychological morbidity in other chronically ill populations. This study aimed to identify the prevalence of body-image disturbance (BID) in a dialysis population, correlation with psychological distress, and to identify any variables associated with increased BID and psychological morbidity. Particular attention was given to cognitive models of emotion which postulate a key role for self-consciousness and appearance-related beliefs. Between May and August 2007, 97 adult haemodialysis and peritoneal dialysis patients from a UK regional specialist centre responded to a questionnaire survey. Outcome measures comprised the Body Image Disturbance Questionnaire, Hospital Anxiety and Depression Scale, Self-consciousness Scale and the Appearance Schemas Inventory-Revised. Prevalence of anxiety and depression was 24.7% and 18.6%, respectively, with levels of BID significantly above community norms for both male and female respondents. Significant associations were found between psychological morbidity and BID and with specific aspects of appearance-schematisation and self-focus. Patients should be educated regarding the likely physical consequences of dialysis-types to aid decision-making and prepare them for impacts once dialysis is commenced. Clinicians may wish to monitor dialysis-users for distress and BI difficulties at follow-up appointments. Interventions that target appearance-related beliefs and BID may be of benefit to this population.

Feasibility and Safety of Intra-Dialysis Yoga and Education in Maintenance Hemodialysis Patients

PubMed Central

Birdee, Gurjeet S.; Rothman, Russell L.; Sohl, Stephanie J.; Wertenbaker, Dolphi; Wheeler, Amy; Bossart, Chase; Balasire, Oluwaseyi; Ikizler, T. Alp

2016-01-01

Objective Patients with end-stage renal disease on maintenance hemodialysis are much more sedentary than healthy individuals. The purpose of this study was to assess the feasibility and safety of a 12-week intra-dialysis yoga intervention versus a kidney education intervention on the promotion of physical activity. Design and Methods We randomized participants by dialysis shift to either 12-week intra-dialysis yoga or an educational intervention. Intra-dialysis yoga was provided by yoga teachers to participants while receiving hemodialysis. Participants receiving the 12-week educational intervention received a modification of a previously developed comprehensive educational program for patients with kidney disease (“Kidney School”). The primary outcome for this study was feasibility based on recruitment and adherence to the interventions, and safety of intra-dialysis yoga. Secondary outcomes were to determine the feasibility of administering questionnaires at baseline and 12-weeks including the Kidney Disease-Related Quality of Life-36. Results Among 56 eligible patients approached for the study, 55% (n=31) were interested and consented to participation with 18 assigned to intra-dialysis yoga and 13 to the educational program. A total of 5 participants withdrew from the pilot study, all from the intra-dialysis yoga group. Two of these participants reported no further interest in participation. Three withdrawn participants switched dialysis times and therefore could no longer receive intra-dialysis yoga. As a result, 72% (13 of 18) and 100% (13 of 13) of participants completed 12-week intra-dialysis yoga and educational programs, respectively. There were no adverse events related to intra-dialysis yoga. Intervention participants practiced yoga a median of 21 sessions (70% participation frequency), with 60% of participants practicing at least 2 times a week. Participants in the educational program completed a median of 30 sessions (83% participation frequency

Recovery of renal function in dialysis patients

PubMed Central

Agraharkar, Mahendra; Nair, Vasudevan; Patlovany, Matthew

2003-01-01

Background Although recovery of renal functions in dialysis dependent patients is estimated to be greater than 1%, there are no indicators that actually suggest such revival of renal function. Residual renal function in dialysis patients is unreliable and seldom followed. Therefore renal recovery (RR) in dialysis dependent patients may remain unnoticed. We present a group of dialysis dependent patients who regained their renal functions. The aim of this project is to determine any indicators that may identify the recovery of renal functions in dialysis dependent patients. Methods All the discharges from the chronic dialysis facilities were identified. Among these discharges deaths, transplants, voluntary withdrawals and transfers either to another modality or another dialysis facility were excluded in order to isolate the patients with RR. The dialysis flow sheets and medical records of these patients were subsequently reviewed. Results Eight patients with a mean age of 53.8 ± 6.7 years (± SEM) were found to have RR. Dialysis was initiated due to uremic symptoms in 6 patients and fluid overload in the remaining two. The patients remained dialysis dependent for 11.1 ± 4.2 months. All these patients had good urine output and 7 had symptoms related to dialysis. Their mean pre-initiation creatinine and BUN levels were 5.21 ± 0.6 mg/dl and 72.12 ± 11.12 mg/dl, respectively. Upon discontinuation, they remained dialysis free for 19.75 ± 5.97 months. The mean creatinine and BUN levels after cessation of dialysis were 2.85 ± 0.57 mg/dl and 29.62 ± 5.26 mg/dl, respectively, while the mean creatinine clearance calculated by 24-hour urine collection was 29.75 ± 4.78 ml/min. One patient died due to HIV complications. One patient resumed dialysis after nine months. Remaining continue to enjoy a dialysis free life. Conclusion RR must be considered in patients with good urine output and unresolved acute renal failure. Dialysis intolerance may be an indicator of RR among

Dialysis Facility and Patient Characteristics Associated with Utilization of Home Dialysis

PubMed Central

Walker, David R.; Inglese, Gary W.; Sloand, James A.

2010-01-01

Background and objectives: Nonmedical factors influencing utilization of home dialysis at the facility level are poorly quantified. Home dialysis is comparably effective and safe but less expensive to society and Medicare than in-center hemodialysis. Elimination of modifiable practice variation unrelated to medical factors could contribute to improvements in patient outcomes and use of scarce resources. Design, setting, participants, & measurements: Prevalent dialysis patient data by facility were collected from the 2007 ESRD Network’s annual reports. Facility characteristic data were collected from Medicare’s Dialysis Facility Compare file. A multivariate regression model was used to evaluate associations between the use of home dialysis and facility characteristics. Results: The utilization of home dialysis was positively associated with facility size, percent patients employed full- or part-time, younger population, and years a facility was Medicare certified. Variables negatively associated include an increased number of hemodialysis patients per hemodialysis station, chain association, rural location, more densely populated zip code, a late dialysis work shift, and greater percent of black patients within a zip code. Conclusions: Improved understanding of factors affecting the frequency of use of home dialysis may help explain practice variations across the United States that result in an imbalanced use of medical resources within the ESRD population. In turn, this may improve the delivery of healthcare and extend the ability of an increasingly overburdened medical financing system to survive. PMID:20634324

Dialysis facility and patient characteristics associated with utilization of home dialysis.

PubMed

Walker, David R; Inglese, Gary W; Sloand, James A; Just, Paul M

2010-09-01

Nonmedical factors influencing utilization of home dialysis at the facility level are poorly quantified. Home dialysis is comparably effective and safe but less expensive to society and Medicare than in-center hemodialysis. Elimination of modifiable practice variation unrelated to medical factors could contribute to improvements in patient outcomes and use of scarce resources. Prevalent dialysis patient data by facility were collected from the 2007 ESRD Network's annual reports. Facility characteristic data were collected from Medicare's Dialysis Facility Compare file. A multivariate regression model was used to evaluate associations between the use of home dialysis and facility characteristics. The utilization of home dialysis was positively associated with facility size, percent patients employed full- or part-time, younger population, and years a facility was Medicare certified. Variables negatively associated include an increased number of hemodialysis patients per hemodialysis station, chain association, rural location, more densely populated zip code, a late dialysis work shift, and greater percent of black patients within a zip code. Improved understanding of factors affecting the frequency of use of home dialysis may help explain practice variations across the United States that result in an imbalanced use of medical resources within the ESRD population. In turn, this may improve the delivery of healthcare and extend the ability of an increasingly overburdened medical financing system to survive.

Medication apprehension and compliance among dialysis patients--a comprehensive guidance attitude.

PubMed

Katzir, Ze'ev; Boaz, Mona; Backshi, Irena; Cernes, Relu; Barnea, Zvi; Biro, Alexander

2010-01-01

Compliance with treatment regimens is a continuing challenge for chronic dialysis patients and their medical caregivers. Poor patient adherence to prescribed medications can adversely affect treatment outcome. In this pre- versus post-intervention study, 89 chronic dialysis patients [75 hemodialysis (HD), 14 continuous ambulatory peritoneal dialysis (CAPD); mean age 62.7 +/- 12.39 years, 34 females] responded to a written questionnaire designed to assess knowledge about and compliance with 5 groups of prescribed medications: metabolic drugs, antihypertensives, cardiac-supporting agents, peptic disease therapy and hematological replacement therapy. Mode of intake, storage, means of supply and source of information for each class of drug were also assessed. Patients then received both oral and written instructions regarding their prescribed medications (intervention). This information was repeated 3 months later. Six months after the intervention, patients were re-administered the questionnaires. Response to the questionnaires and laboratory data were compared prior to and following the intervention. Overall, compliance with prescribed medications significantly improved following the intervention, from 89 to 95.7%, p = 0.0007. This relative improvement was greater in HD than CAPD patients (27 vs. 2%, p < 0.0001). Improvement in compliance was associated with lower initial scores, fewer years of education, and longer dialysis vintage. Compared to baseline values, post-intervention blood hemoglobin, hematocrit, mean corpuscular volume, ferritin and Ca levels were significantly improved. Dialysis patients appear to benefit from receiving comprehensive guidance about medications, in terms of compliance with medications and blood chemistry and hematology measures. (c) 2009 S. Karger AG, Basel.

Impact of Pre-Dialysis Care on Clinical Outcomes in Peritoneal Dialysis Patients.

PubMed

Spigolon, Dandara N; de Moraes, Thyago P; Figueiredo, Ana E; Modesto, Ana Paula; Barretti, Pasqual; Bastos, Marcus Gomes; Barreto, Daniela V; Pecoits-Filho, Roberto

2016-01-01

Structured pre-dialysis care is associated with an increase in peritoneal dialysis (PD) utilization, but not with peritonitis risk, technical and patient survival. This study aimed at analyzing the impact of pre-dialysis care on these outcomes. All incident patients starting PD between 2004 and 2011 in a Brazilian prospective cohort were included in this analysis. Patients were divided into 2 groups: early pre-dialysis care (90 days of follow-up by a nephrology team); and late pre-dialysis care (absent or less than 90 days follow-up). The socio-demographic, clinical and biochemical characteristics between the 2 groups were compared. Risk factors for the time to the first peritonitis episode, technique failure and mortality based on Cox proportional hazards models. Four thousand one hundred seven patients were included. Patients with early pre-dialysis care presented differences in gender (female - 47.0 vs. 51.1%, p = 0.01); race (white - 63.8 vs. 71.7%, p < 0.01); education (<4 years - 61.9 vs. 71.0%, p < 0.01), respectively, compared to late care. Patients with early pre-dialysis care presented a higher prevalence of comorbidities, lower levels of creatinine, phosphorus, and glucose with a significantly better control of hemoglobin and potassium serum levels. There was no impact of pre-dialysis care on peritonitis rates (hazard ratio (HR) 0.88; 95% CI 0.77-1.01) and technique survival (HR 1.12; 95% CI 0.92-1.36). Patient survival (HR 1.20; 95% CI 1.03-1.41) was better in the early pre-dialysis care group. Earlier pre-dialysis care was associated with improved patient survival, but did not influence time to the first peritonitis nor technique survival in this national PD cohort. © 2016 S. Karger AG, Basel.

[News in peritoneal dialysis].

PubMed

Ryckelynck, Jean-Philippe; Lobbedez, Thierry; Ficheux, Maxence; Bonnamy, Cécile; El Haggan, Waël; Henri, Patrick; Chatelet, Valérie; Levaltier, Béatrice; Hurault de Ligny, Bruno

2007-12-01

Peritoneal dialysis, like hemodialysis, is a first-line therapy for patients with end-stage renal disease. Progress in medical devices and materials has reduced infectious complications such as peritonitis and catheter exit-site infections and thus decreased morbidity. Peritoneal dialysis fluids are increasingly biocompatible, result in fewer glucose degradation products, protect the peritoneal membrane better and thus improve tolerance. The maintenance of residual renal function, together with better comfort and no pain, help control the fluid and sodium balance. Automated peritoneal dialysis can be performed each night, either autonomously or assisted by a visiting nurse twice a day (to prepare, connect, and disconnect the machine). This treatment can thus be provided to most patients, regardless of their age. Peritoneal dialysis is indicated principally for young people waiting for a kidney transplantation (to preserve their vascular network), elderly patients who wish to remain either at home or in an institution, and patients with cardiac insufficiency, because of the better hemodynamic tolerance. Numerous obstacles, mainly nonmedical, still impede the development of peritoneal dialysis. Patients seen in emergencies start hemodialysis without necessarily receiving any information about peritoneal dialysis. Indeed, neither physicians nor patients receive adequate information.

Arthritis associated with calcium oxalate crystals in an anephric patient treated with peritoneal dialysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Rosenthal, A.; Ryan, L.M.; McCarty, D.J.

1988-09-02

The authors report a case of calcium oxalate arthropathy in a woman undergoing intermittent peritoneal dialysis who was not receiving pharmacologic doses of ascorbic acid. She developed acute arthritis, with calcium oxalate crystals in Heberden's and Bouchard's nodes, a phenomenon previously described in gout. Intermittent peritoneal dialysis may be less efficient than hemodialysis in clearing oxalate, and physicians should now consider calcium oxalate-associated arthritis in patients undergoing peritoneal dialysis who are not receiving large doses of ascorbic acid.

Disaster preparedness of dialysis patients for Hurricanes Gustav and Ike 2008.

PubMed

Kleinpeter, Myra A

2009-01-01

Hurricanes Katrina and Rita resulted in massive devastation of the Gulf Coast at Mississippi, Louisiana, and Texas during 2005. Because of those disasters, dialysis providers, nephrologists, and dialysis patients used disaster planning activities to work to mitigate the morbidity and mortality associated with the 2005 hurricane season for future events affecting dialysis patients. As Hurricane Gustav approached, anniversary events for Hurricane Katrina were postponed because of evacuation orders for nearly the entire Louisiana Gulf Coast. As part of the hurricane preparation, dialysis units reviewed the disaster plans of patients, and patients made preparation for evacuation. Upon evacuation, many patients returned to the dialysis units that had provided services during their exile from Hurricane Katrina; other patients went to other locations as part of their evacuation plan. Patients uniformly reported positive experiences with dialysis providers in their temporary evacuation communities, provided that those communities did not experience the effects of Hurricane Gustav. With the exception of evacuees to Baton Rouge, patients continued to receive their treatments uninterrupted. Because of extensive damage in the Baton Rouge area, resulting in widespread power losses and delayed restoration of power to hospitals and other health care facilities, some patients missed one treatment. However, as a result of compliance with disaster fluid and dietary recommendations, no adverse outcomes occurred. In most instances, patients were able to return to their home dialysis unit or a nearby unit to continue dialysis treatments within 4 - 5 days of Hurricane Gustav. Hurricane Ike struck the Texas Gulf Coast near Galveston, resulting in devastation of that area similar to the devastation seen in New Orleans after Katrina. The storm surge along the Louisiana Gulf Coast resulted in flooding that temporarily closed coastal dialysis units. Patients were prepared and experienced

Self-reported adherence to a therapeutic regimen among patients undergoing continuous ambulatory peritoneal dialysis.

PubMed

Lam, Lai Wah; Twinn, Sheila F; Chan, Sally W C

2010-04-01

This paper is a report of a study conducted to examine self-reported adherence to a therapeutic regimen for continuous ambulatory peritoneal dialysis. Studies of patients' adherence during dialysis have primarily focused on haemodialysis and have frequently yielded inconsistent results, which are attributed to the inconsistent tools used to measure adherence. Levels of adherence to all four components of the therapeutic regimen (i.e. dietary and fluid restrictions, medication, and the dialysis regimen) among patients receiving peritoneal dialysis have not been examined, especially from a patient perspective. A total population sample was used. A cross-sectional survey was carried out by face-to-face interviews in 2005 in one renal clinic in Hong Kong. A total of 173 patients undergoing peritoneal dialysis (56% of the total population) participated in the study. Patients perceived themselves as more adherent to medication (83%; 95% confidence interval 77-88%) and dialysis (93%; 95% confidence interval 88-96%) prescriptions than to fluid (64%; 95% confidence interval 56-71%) and dietary (38%; 95% confidence interval 30-45%) restrictions. Those who were male, younger or had received dialysis for 1-3 years saw themselves as more non-adherent compared with other patients. Healthcare professionals should take cultural issues into consideration when setting dietary and fluid restriction guidelines. Additional attention and support are required for patients who identify themselves as more non-adherent. To help patients live with end-stage renal disease and its treatment, qualitative research is required to understand how they go through the dynamic process of adherence.

Depression in dialysis patients.

PubMed

King-Wing Ma, Terry; Kam-Tao Li, Philip

2016-08-01

Depression is the most common psychiatric illness in patients with end-stage renal disease (ESRD). The reported prevalence of depression in dialysis population varied from 22.8% (interview-based diagnosis) to 39.3% (self- or clinician-administered rating scales). Such differences were attributed to the overlapping symptoms of uraemia and depression. Systemic review and meta-analysis of observational studies showed that depression was a significant predictor of mortality in dialysis population. The optimal screening tool for depression in dialysis patients remains uncertain. The Beck Depression Inventory (BDI), Patient Health Questionnaire (PHQ) and Center for Epidemiologic Studies Depression Scale (CESD) have been validated for screening purposes. Patients who scored ≥14 using BDI should be referred to a psychiatrist for early evaluation. Structured Clinical Interview for DSM disorders (SCID) remains the gold standard for diagnosis. Non-pharmacological treatment options include cognitive behavioural therapy and exercise training programs. Although frequent haemodialysis may have beneficial effects on patients' physical and mental well-being, it cannot and should not be viewed as a treatment of depression. Selective serotonin reuptake inhibitors (SSRIs) are generally effective and safe in ESRD patients, but most studies were small, non-randomized and uncontrolled. The European Renal Best Practice (ERBP) guideline suggests a trial of SSRI for 8 to 12 weeks in dialysis patients who have moderate-major depression. The treatment effect should be re-evaluated after 12 weeks to avoid prolonging ineffective medication. This review will discuss the current understanding in the diagnosis and management of depression in dialysis patients. © 2016 Asian Pacific Society of Nephrology.

Barriers to medication adherence and its relationship with outcomes in pediatric dialysis patients.

PubMed

Silverstein, Douglas M; Fletcher, Angela; Moylan, Kathleen

2014-08-01

Medication adherence is a major factor determining outcome in children with chronic disease. Children with end-stage renal disease are challenged with requirements for renal replacement therapy in addition to complicated medication regimens. We assessed barriers to medication adherence in 22 pediatric patients receiving chronic dialysis [63.6 % hemodialysis (HD), 36.4 % peritoneal dialysis (PD); age 15.9 ± 0.7 years, dialysis vintage 31.6 ± 6.5 months]. Adherence was assessed by a 16-question survey with a maximum score (difficulty) of 64. The overall mean adherence score was 30.9 ± 2.4 (range 16-49; median  27.5). There was a trend for lower adherence scores in patients on HD (27.5 ± 2.9) compared to those on PD (36.8 ± 3.7) (p = 0.06). Compared to HD patients, the mean score/question was significantly higher in PD patients (1.7 ± 0.2 vs. 2.4 ± 0.2, respectively; p = 0.006). Of the 16 questions, HD and PD patients gave a mean response of ≤1.2 for five and zero questions, respectively. Neither gender, age nor dialysis vintage was related to adherence scores. There was also a trend for adherence scores to be higher in females (35.6 ± 3.7) than in males (27.5 ± 2.9) (p = 0.1), but this difference did not reach statistical significance. Markers of mineral bone disease were similar in HD and PD patients. Among all targets in HD and PD patients combined, there was no relationship between adherence scores and number of targets reached (r = -0.09, p = 0.7). There are many barriers to medication adherence in pediatric patients receiving dialysis. In our patient group the difficulties were more evident in patients receiving PD than in those receiving HD.

Nervous system disorders in dialysis patients.

PubMed

Bansal, Vinod K; Bansal, Seema

2014-01-01

Neurologic complications are frequently encountered in dialysis patients. These may be due to the uremic state or to dialysis therapy, and require careful assessment. With longer survival of dialysis patients, these neurologic complications may significantly affect morbidity, mortality, and patients' well-being. Central nervous system involvement includes uremic encephalopathy as well as dialysis disequilibrium disorder. Both are rarely seen because of current improved understanding of their pathogenesis and treatment. Manifestations of atherosclerosis, stroke, and other neuropathies are present in this population and are not significantly altered by dialysis therapy. In recent years, increasing numbers of sleep disorders are being recognized. Peripheral nervous system involvement is also noted, including myopathy and related categories. In this chapter, we address clinical and pathophysiologic aspects of nervous system disorders in dialysis patients while discussing available therapeutic options to address the neurologic involvement. © 2014 Elsevier B.V. All rights reserved.

Associations of depressive symptoms and pain with dialysis adherence, health resource utilization, and mortality in patients receiving chronic hemodialysis.

PubMed

Weisbord, Steven D; Mor, Maria K; Sevick, Mary Ann; Shields, Anne Marie; Rollman, Bruce L; Palevsky, Paul M; Arnold, Robert M; Green, Jamie A; Fine, Michael J

2014-09-05

Depressive symptoms and pain are common in patients receiving chronic hemodialysis, yet their effect on dialysis adherence, health resource utilization, and mortality is not fully understood. This study sought to characterize the longitudinal associations of these symptoms with dialysis adherence, emergency department (ED) visits, hospitalizations, and mortality. As part of a trial comparing symptom management strategies in patients receiving chronic hemodialysis, this study prospectively assessed depressive symptoms using the Patient Health Questionnaire 9, and pain using the Short-Form McGill Pain Questionnaire, monthly between 2009 and 2011. This study used negative binomial, Poisson, and proportional hazards regression to analyze the longitudinal associations of depressive symptoms and pain, scaled based on 5-point increments in symptom scores, with missed and abbreviated hemodialysis treatments, ED visits, hospitalizations, and mortality, respectively. Among 286 patients, moderate-to-severe depressive symptoms were identified on 788 of 4452 (18%) assessments and pain was reported on 3537 of 4459 (79%) assessments. Depressive symptoms were independently associated with missed (incident rate ratio [IRR], 1.21; 95% confidence interval [95% CI], 1.10 to 1.33) and abbreviated (IRR, 1.08; 95% CI, 1.03 to 1.14) hemodialysis treatments, ED visits (IRR, 1.24; 95% CI, 1.12 to 1.37), hospitalizations (IRR, 1.19; 95% CI, 1.10 to 1.30), and mortality (IRR, 1.40; 95% CI, 1.11 to 1.77). Pain was independently associated with abbreviated hemodialysis treatments (IRR, 1.03; 95% CI, 1.01 to 1.06) and hospitalizations (IRR, 1.05; 95% CI, 1.00 to 1.10). Severe pain was independently associated with abbreviated hemodialysis treatments (IRR, 1.16; 95% CI, 1.06 to 1.28), ED visits (IRR, 1.58; 95% CI, 1.28 to 1.94), and hospitalizations (IRR, 1.22; 95% CI, 1.03 to 1.45), but not mortality (hazard ratio, 1.71; 95% CI, 0.81 to 2.96). Depressive symptoms and pain are independently

Associations of Depressive Symptoms and Pain with Dialysis Adherence, Health Resource Utilization, and Mortality in Patients Receiving Chronic Hemodialysis

PubMed Central

Mor, Maria K.; Sevick, Mary Ann; Shields, Anne Marie; Rollman, Bruce L.; Palevsky, Paul M.; Arnold, Robert M.; Green, Jamie A.; Fine, Michael J.

2014-01-01

Background and objectives Depressive symptoms and pain are common in patients receiving chronic hemodialysis, yet their effect on dialysis adherence, health resource utilization, and mortality is not fully understood. This study sought to characterize the longitudinal associations of these symptoms with dialysis adherence, emergency department (ED) visits, hospitalizations, and mortality. Design, setting, participants, & measurements As part of a trial comparing symptom management strategies in patients receiving chronic hemodialysis, this study prospectively assessed depressive symptoms using the Patient Health Questionnaire 9, and pain using the Short-Form McGill Pain Questionnaire, monthly between 2009 and 2011. This study used negative binomial, Poisson, and proportional hazards regression to analyze the longitudinal associations of depressive symptoms and pain, scaled based on 5-point increments in symptom scores, with missed and abbreviated hemodialysis treatments, ED visits, hospitalizations, and mortality, respectively. Results Among 286 patients, moderate-to-severe depressive symptoms were identified on 788 of 4452 (18%) assessments and pain was reported on 3537 of 4459 (79%) assessments. Depressive symptoms were independently associated with missed (incident rate ratio [IRR], 1.21; 95% confidence interval [95% CI], 1.10 to 1.33) and abbreviated (IRR, 1.08; 95% CI, 1.03 to 1.14) hemodialysis treatments, ED visits (IRR, 1.24; 95% CI, 1.12 to 1.37), hospitalizations (IRR, 1.19; 95% CI, 1.10 to 1.30), and mortality (IRR, 1.40; 95% CI, 1.11 to 1.77). Pain was independently associated with abbreviated hemodialysis treatments (IRR, 1.03; 95% CI, 1.01 to 1.06) and hospitalizations (IRR, 1.05; 95% CI, 1.00 to 1.10). Severe pain was independently associated with abbreviated hemodialysis treatments (IRR, 1.16; 95% CI, 1.06 to 1.28), ED visits (IRR, 1.58; 95% CI, 1.28 to 1.94), and hospitalizations (IRR, 1.22; 95% CI, 1.03 to 1.45), but not mortality (hazard ratio, 1

Risk factor and cost accounting analysis for dialysis patients in Taiwan.

PubMed

Su, Bin-Guang; Tsai, Kai-Li; Yeh, Shu-Hsing; Ho, Yi-Yi; Liu, Shin-Yi; Rivers, Patrick A

2010-05-01

According to the 2004 US Renal Data System's annual report, the incidence rate of chronic renal failure in Taiwan increased from 120 to 352 per million populations between 1990 and 2003. This incidence rate is the highest in the world. The prevalence rate, which ranks number two in the world (Japan ranks number one), also increased from 384 to 1630 per million populations. Based on 2005 Taiwan national statistics, there were 52,958 end-stage renal disease (ESRD) patients receiving routine dialysis treatment. This number, which comprised less than 0.2% of the total population and consumed $2.6 billion New Taiwan dollars, was more than 6.12% of the total annual spending of national health insurance during 2005. Dialysis expenditures for patients with ESRD rank the highest among all major injuries (traumas) and diseases. This article identifies and discusses the risk factors associated with consumption of medical resources during dialysis. Instead of using reimbursement data to estimate cost, as seen in previous studies, this study uses cost data within organizations and focuses on evaluating and predicting the resource consumption pattern for dialysis patients with different risk factors. Multiple regression analysis was used to identify 23 risk factors for routine dialysis patients. Of these risk factors, six were associated with the increase of dialysis cost: age (i.e. 75 years old and older), liver function disorder, hypertension, bile-duct disorder, cancer and high blood lipids. Patients with liver function disorder incurred much higher costs for injection medication and supplies. Hypertensive patients incurred higher costs for injection medication, supplies and oral medication. Patients with bile-duct disorder incurred a significant difference in check-up costs (i.e. costs were higher for those aged 75 years and older than those who were younger than 30 years of age). Cancer patients also incurred significant differences in cost of medical supplies. Patients

Micrococcus species-related peritonitis in patients receiving peritoneal dialysis.

PubMed

Kao, Chih-Chin; Chiang, Chih-Kang; Huang, Jenq-Wen

2014-01-01

Peritonitis is a major complication of peritoneal dialysis (PD) and remains the most common cause of PD failure. Micrococci are catalase-positive, coagulase-negative, and gram-positive cocci that are spherical, often found in tetrad, and belong to the family Micrococcaceae. Micrococcus species are commonly found in the environment, and it is now recognized that Micrococcus species can be opportunistic pathogens in immunocompromised patients. The only consistent predisposing factor for Micrococcus infection is an immunocompromised state. We report three cases of Micrococcus PD peritonitis. Improper practice of PD may have been the causative factor. Although Micrococcus species are low-virulence pathogens, infection could result in refractory peritonitis and subsequent PD failure. Intraperitoneal administration of vancomycin for at least 2 weeks is recommended for Micrococcus peritonitis.

Long-Term Effects of Spironolactone in Peritoneal Dialysis Patients

PubMed Central

Mizuno, Masashi; Suzuki, Yasuhiro; Tamai, Hirofumi; Hiramatsu, Takeyuki; Ohashi, Hiroshige; Ito, Isao; Kasuga, Hirotake; Horie, Masanobu; Maruyama, Shoichi; Yuzawa, Yukio; Matsubara, Tatsuaki; Matsuo, Seiichi

2014-01-01

ESRD treated with dialysis is associated with increased left ventricular hypertrophy, which, in turn, is related to high mortality. Mineralocorticoid receptor antagonists improve survival in patients with chronic heart failure; however, the effects in patients undergoing dialysis remain uncertain. We conducted a multicenter, open-label, prospective, randomized trial with 158 patients receiving angiotensin-converting enzyme inhibitor or angiotensin type 1 receptor antagonist and undergoing peritoneal dialysis with and without (control group) spironolactone for 2 years. As a primary endpoint, rate of change in left ventricular mass index assessed by echocardiography improved significantly at 6 (P=0.03), 18 (P=0.004), and 24 (P=0.01) months in patients taking spironolactone compared with the control group. Rate of change in left ventricular ejection fraction improved significantly at 24 weeks with spironolactone compared with nontreatment (P=0.02). The benefits of spironolactone were clear in patients with reduced residual renal function. As secondary endpoints, renal Kt/V and dialysate-to-plasma creatinine ratio did not differ significantly between groups during the observation period. No serious adverse effects, such as hyperkalemia, occurred. In this trial, spironolactone prevented cardiac hypertrophy and decreases in left ventricular ejection fraction in patients undergoing peritoneal dialysis, without significant adverse effects. Further studies, including those to determine relative effectiveness in women and men and to evaluate additional secondary endpoints, should confirm these data in a larger cohort. PMID:24335969

Zinc Supplementation Alters Plasma Aluminum and Selenium Status of Patients Undergoing Dialysis: A Pilot Study

PubMed Central

Guo, Chih-Hung; Chen, Pei-Chung; Hsu, Guoo-Shyng W.; Wang, Chia-Liang

2013-01-01

End stage renal disease patients undergoing long-term dialysis are at risk for abnormal concentrations of certain essential and non-essential trace metals and high oxidative stress. We evaluated the effects of zinc (Zn) supplementation on plasma aluminum (Al) and selenium (Se) concentrations and oxidative stress in chronic dialysis patients. Zn-deficient patients receiving continuous ambulatory peritoneal dialysis or hemodialysis were divided into two groups according to plasma Al concentrations (HA group, Al > 50 μg/L; and MA group, Al > 30 to ≤ 50 μg/L). All patients received daily oral Zn supplements for two months. Age- and gender-matched healthy individuals did not receive Zn supplement. Clinical variables were assessed before, at one month, and after the supplementation period. Compared with healthy subjects, patients had significantly lower baseline plasma Se concentrations and higher oxidative stress status. After two-month Zn treatment, these patients had higher plasma Zn and Se concentrations, reduced plasma Al concentrations and oxidative stress. Furthermore, increased plasma Zn concentrations were related to the concentrations of Al, Se, oxidative product malondialdehyde (MDA), and antioxidant enzyme superoxide dismutase activities. In conclusion, Zn supplementation ameliorates abnormally high plasma Al concentrations and oxidative stress and improves Se status in long-term dialysis patients. PMID:23609777

Quality of Life and Self-Efficacy in Three Dialysis Modalities: Incenter Hemodialysis, Home Hemodialysis, and Home Peritoneal Dialysis.

PubMed

Wright, Linda S; Wilson, Linda

2015-01-01

Previous research has demonstrated improved outcomes for patients on dialysis who have better quality of life and self-efficacy, but has focused almost exclusively on those receiving hemodialysis. The goal of this study was to describe the quality of life and self-efficacy of patients receiving incenter hemodialysis versus those receiving a home dialysis modality (hemodialysis or peritoneal dialysis). The study utilized a correlational cross-sectional design and quota sampling methods. Participants were recruited from outpatient dialysis facilities and included 77 community dwelling adult patients who had been on dialysis for at least six months. Quality of life was measured using the Kidney Disease Quality of Life instrument, and self-efficacy was measured using the Strategies Used by People to Promote Health instrument. Findings suggest equal outcomes between treatment groups, with no contraindication to the use of home therapies.

Dialysis Patient Perspectives on CKD Advocacy: A Semistructured Interview Study.

PubMed

Schober, Gregory S; Wenger, Julia B; Lee, Celeste C; Oberlander, Jonathan; Flythe, Jennifer E

2017-01-01

Health advocacy groups provide education, raise public awareness, and engage in legislative, scientific, and regulatory processes to advance funding and treatments for many diseases. Despite a high burden of chronic kidney disease (CKD) in the United States, public awareness and research funding lag behind those for other disease states. We undertook this study of patients receiving maintenance dialysis to describe knowledge and beliefs about CKD advocacy, understand perceptions regarding advocacy participation, and elicit ideas for generating more advocacy in the dialysis community. Qualitative study. 48 patients (89% response rate) receiving in-center hemodialysis (n=39), home hemodialysis (n=4), and peritoneal dialysis (n=5) from 14 US states. Semistructured interviews. Transcripts were thematically analyzed. 5 themes describing patient perspectives on CKD advocacy were identified: (1) advocacy awareness (advocacy vs engagement knowledge, concrete knowledge, CKD publicity), (2) willingness to participate (personal qualities, internal efficacy, external efficacy), (3) motivations (altruism, providing a purpose, advancement of personal health, self-education), (4) resource availability (time, financial and transportation, health status), and (5) mobilization experience (key figure, mobilization network). Participants displayed operational understanding of advocacy but generally lacked knowledge about specific opportunities for participation. Personal qualities and external efficacy were perceived as important for advocacy participation, as were motivating factors such as altruism and self-education. Resources factored heavily into perceived participation ability. Most participants identified a key figure who invited them to participate in advocacy. In-person patient-delivered communication about advocacy opportunities was identified as critical to enhancing CKD advocacy among patients living on dialysis therapy. Potential selection bias and inclusion of only

Older patients undergoing dialysis treatment: cognitive functioning, depressive mood and health-related quality of life.

PubMed

Tyrrell, J; Paturel, L; Cadec, B; Capezzali, E; Poussin, G

2005-07-01

An increasing number of older patients receive dialysis treatment to compensate for deficient kidneys due to end-stage renal disease (ESRD). Ethical questions arise about the benefits of dialysis when a patient appears unwilling or unable to comply with this treatment procedure. Such attitudes and behaviour may be due to psychological factors, but these are not routinely assessed. The purpose of this study was to evaluate levels of cognitive impairment, depressive mood and self-reported quality of life in older dialysis patients (>70 years). A total of 51 outpatients receiving dialysis were assessed by psychologists, using a depression scale (MADRS), two cognitive tests (MMSE and BEC 96), and a quality of life questionnaire (NHP). Sixty percent of the patients were depressed, and between 30-47% had cognitive impairment. Almost half of the depressed patients were also cognitively impaired. The scores for self-reported quality of life varied widely within the sample. Cognitive impairment and depressive mood are often overlooked and underestimated in this population. Regular assessments of depressive mood, cognitive ability and quality of life are recommended, given the prevalence of problems in these domains for older dialysis patients. The information obtained should assist staff as they reflect on individual cases where the benefits of continuing treatment are being examined.

Factors Associated with the Choice of Peritoneal Dialysis in Patients with End-Stage Renal Disease.

PubMed

Chiang, Pei-Chun; Hou, Jia-Jeng; Jong, Ing-Ching; Hung, Peir-Haur; Hsiao, Chih-Yen; Ma, Tsung-Liang; Hsu, Yueh-Han

2016-01-01

The purpose of this study was to analyze the factors associated with receiving peritoneal dialysis (PD) in patients with incident end-stage renal disease (ESRD) in a hospital in Southern Taiwan. The study included all consecutive patients with incident ESRD who participated in a multidisciplinary predialysis education (MPE) program and started their first dialysis therapy between January 1, 2008, and June 30, 2013, in the study hospital. We provided small group teaching sessions to advanced CKD patients and their family to enhance understanding of various dialysis modalities. Multivariate logistic regression models were used to analyze the association of patient characteristics with the chosen dialysis modality. Of the 656 patients, 524 (80%) chose hemodialysis and 132 chose PD. Our data showed that young age, high education level, and high scores of activities of daily living (ADLs) were positively associated with PD treatment. Patients who received small group teaching sessions had higher percentages of PD treatment (30.5% versus 19.5%; P = 0.108) and preparedness for dialysis (61.1% versus 46.6%; P = 0.090). Young age, high education level, and high ADL score were positively associated with choosing PD. Early creation of vascular access may be a barrier for PD.

[Patients in pre-dialysis: decision taking and free choice of treatment].

PubMed

Sarrias Lorenz, X; Bardón Otero, E; Vila Paz, M L

2008-01-01

treatment. Because of the impossibility of establishing universal rules of proportionality, it is necessary to make a personal judgment of conscience in each specific case. Recommendations for initiation or not of dialysis: Taking shared decisions between the patient (or relatives and/or advisors) and the physician. These shared decisions will be documented with signing of the proposed informed consent or rejection of the treatment. The medical team should always be sure that the patients has fully understood the consequences of the decision taken. Explanation of the modalities should include: - Types of dialysis treatment available. - Not to initiate dialysis and continue with conservative treatment until death. This situation may cause many problems if we do not have the help of the palliative care service. - Try dialysis for a limited time. - Stop dialysis and receive medical care until death. - Evaluate the prognosis of renal disease and concomitant diseases, life expectancy and family support. Resolution of conflicts: Conflicts may occur: - Between nephrologist and patient/family. - Between members of the nephrological team. - Between nephrologist and other physicians. When conflicts persist and the need for initiation of dialysis is urgent, it is necessary to initiate treatment and continue it until the resolution of these conflicts, making a record of this decision. In such cases, the Hospital Ethics Care Committee can help with appropriate advice to solve the discrepancies. Decisions taken in advance may be useful in this type of patients. Patients with advanced chronic kidney disease with criteria for Noninclusion or withdrawal of dialysis. - Severe or irreversible dementia. - conditions of permanent unconsciousness. - advanced tumors with metastasis. - terminal disease of another nontransplantable organ. - severe physical and/or mental disabilities. (Strength of Recommendation C)

New Opportunities for Funding Dialysis-Dependent Undocumented Individuals

PubMed Central

2017-01-01

The cost of dialysis for the estimated 6500 dialysis-dependent undocumented individuals with kidney failure in the United States is high, the quality of dialysis care they receive is poor, and their treatment varies regionally. Some regions use state and matched federal funds to cover regularly scheduled dialysis treatments, while others provide treatment only in emergent life-threatening conditions. Nephrologists caring for patients who receive emergent dialysis are tasked with the difficult moral dilemma of determining “who gets dialysis that day.” Without a path to citizenship and by exclusion from the federal marketplace exchanges, undocumented individuals have limited options for their treatment. A novel opportunity to provide scheduled dialysis for this population is through the purchase of insurance off the exchange. Plans purchased off the exchange must still abide by the 2014 provision of the Patient Protection and Affordable Care Act, which prohibits insurance companies from denying coverage based on a preexisting health condition. In 2015 and 2016, >100 patients previously receiving only emergent dialysis at the two largest safety-net hospital systems in Texas obtained off-the-exchange commercial health insurance plans. These undocumented patients now receive scheduled dialysis treatments, which has improved their care and quality of life, as well as decompressed the overburdened hospital systems. The long-term sustainability of this option is not known. Socially responsive and visionary policymakers allowing the move into this bold, new direction deserve special appreciation. PMID:27577244

Comparison of hospitalization rates among for-profit and nonprofit dialysis facilities.

PubMed

Dalrymple, Lorien S; Johansen, Kirsten L; Romano, Patrick S; Chertow, Glenn M; Mu, Yi; Ishida, Julie H; Grimes, Barbara; Kaysen, George A; Nguyen, Danh V

2014-01-01

The vast majority of US dialysis facilities are for-profit and profit status has been associated with processes of care and outcomes in patients on dialysis. This study examined whether dialysis facility profit status was associated with the rate of hospitalization in patients starting dialysis. This was a retrospective cohort study of Medicare beneficiaries starting dialysis between 2005 and 2008 using data from the US Renal Data System. All-cause hospitalization was examined and compared between for-profit and nonprofit dialysis facilities through 2009 using Poisson regression. Companion analyses of cause-specific hospitalization that are likely to be influenced by dialysis facility practices including hospitalizations for heart failure and volume overload, access complications, or hyperkalemia were conducted. The cohort included 150,642 patients. Of these, 12,985 (9%) were receiving care in nonprofit dialysis facilities. In adjusted models, patients receiving hemodialysis in for-profit facilities had a 15% (95% confidence interval [95% CI], 13% to 18%) higher relative rate of hospitalization compared with those in nonprofit facilities. Among patients receiving peritoneal dialysis, the rate of hospitalization in for-profit versus nonprofit facilities was not significantly different (relative rate, 1.07; 95% CI, 0.97 to 1.17). Patients on hemodialysis receiving care in for-profit dialysis facilities had a 37% (95% CI, 31% to 44%) higher rate of hospitalization for heart failure or volume overload and a 15% (95% CI, 11% to 20%) higher rate of hospitalization for vascular access complications. Hospitalization rates were significantly higher for patients receiving hemodialysis in for-profit compared with nonprofit dialysis facilities.

Are Diuretics Underutilized in Dialysis Patients?

PubMed

Trinh, Emilie; Bargman, Joanne M

2016-09-01

While oral diuretics are commonly used in patients with chronic kidney disease for the management of volume and blood pressure, they are often discontinued upon initiation of dialysis. We suggest that diuretics are considerably underutilized in peritoneal dialysis and haemodialysis patients despite numerous potential benefits and few side effects. Moreover, when diuretics are used, optimal doses are not always prescribed. In peritoneal dialysis, the use of diuretics can improve volume status and minimize the need for higher glucose-containing solutions. In patients on haemodialysis, diuretics can help lessen interdialytic weight gain, resulting in decreased ultrafiltration rates and fewer episodes of intradialytic hypotension. This paper will review the mechanism of action of diuretics in patients with renal insufficiency, quantify the risk of side effects and elaborate on the potential advantages of diuretic use in peritoneal dialysis and hemodialysis patients with residual kidney function. © 2016 Wiley Periodicals, Inc.

Comparison of Hospitalization Rates among For-Profit and Nonprofit Dialysis Facilities

PubMed Central

Johansen, Kirsten L.; Romano, Patrick S.; Chertow, Glenn M.; Mu, Yi; Ishida, Julie H.; Grimes, Barbara; Kaysen, George A.; Nguyen, Danh V.

2014-01-01

Summary Background and objectives The vast majority of US dialysis facilities are for-profit and profit status has been associated with processes of care and outcomes in patients on dialysis. This study examined whether dialysis facility profit status was associated with the rate of hospitalization in patients starting dialysis. Design, setting, participants, & methods This was a retrospective cohort study of Medicare beneficiaries starting dialysis between 2005 and 2008 using data from the US Renal Data System. All-cause hospitalization was examined and compared between for-profit and nonprofit dialysis facilities through 2009 using Poisson regression. Companion analyses of cause-specific hospitalization that are likely to be influenced by dialysis facility practices including hospitalizations for heart failure and volume overload, access complications, or hyperkalemia were conducted. Results The cohort included 150,642 patients. Of these, 12,985 (9%) were receiving care in nonprofit dialysis facilities. In adjusted models, patients receiving hemodialysis in for-profit facilities had a 15% (95% confidence interval [95% CI], 13% to 18%) higher relative rate of hospitalization compared with those in nonprofit facilities. Among patients receiving peritoneal dialysis, the rate of hospitalization in for-profit versus nonprofit facilities was not significantly different (relative rate, 1.07; 95% CI, 0.97 to 1.17). Patients on hemodialysis receiving care in for-profit dialysis facilities had a 37% (95% CI, 31% to 44%) higher rate of hospitalization for heart failure or volume overload and a 15% (95% CI, 11% to 20%) higher rate of hospitalization for vascular access complications. Conclusions Hospitalization rates were significantly higher for patients receiving hemodialysis in for-profit compared with nonprofit dialysis facilities. PMID:24370770

The impact of peritoneal dialysis-related peritonitis on mortality in peritoneal dialysis patients.

PubMed

Ye, Hongjian; Zhou, Qian; Fan, Li; Guo, Qunying; Mao, Haiping; Huang, Fengxian; Yu, Xueqing; Yang, Xiao

2017-06-05

Results concerning the association between peritoneal dialysis-related peritonitis and mortality in peritoneal dialysis patients are inconclusive, with one potential reason being that the time-dependent effect of peritonitis has rarely been considered in previous studies. This study aimed to evaluate whether peritonitis has a negative impact on mortality in a large cohort of peritoneal dialysis patients. We also assessed the changing impact of peritonitis on patient mortality with respect to duration of follow-up. This retrospective cohort study included incident patients who started peritoneal dialysis from 1 January 2006 to 31 December 2011. Episodes of peritonitis were recorded at the time of onset, and peritonitis was parameterized as a time-dependent variable for analysis. We used the Cox regression model to assess whether peritonitis has a negative impact on mortality. A total of 1321 patients were included. The mean age was 48.1 ± 15.3 years, 41.3% were female, and 23.5% with diabetes mellitus. The median (interquartile) follow-up time was 34 (21-48) months. After adjusting for confounders, peritonitis was independently associated with 95% increased risk of all-cause mortality (hazard ratio, 1.95; 95% confidence interval: 1.46-2.60), 90% increased risk of cardiovascular mortality (hazard ratio, 1.90; 95% confidence interval: 1.28-2.81) and near 4-fold increased risk of infection-related mortality (hazard ratio, 4.94; 95% confidence interval: 2.47-9.86). Further analyses showed that peritonitis was not significantly associated with mortality within 2 years of peritoneal dialysis initiation, but strongly influenced mortality in patients dialysed longer than 2 years. Peritonitis was independently associated with higher risk of all-cause, cardiovascular and infection-related mortality in peritoneal dialysis patients, and its impact on mortality was more significant in patients with longer peritoneal dialysis duration.

Peritoneal dialysis is appropriate for elderly patients.

PubMed

Teitelbaum, Isaac

2006-01-01

The utilization of peritoneal dialysis decreases with age. A number of concerns have been raised regarding the suitability of peritoneal dialysis for elderly patients. The purpose of this review is to determine whether these concerns are medically valid. Literature review and synthesis. Most elderly patients possess the manual and cognitive skills necessary to perform peritoneal dialysis. Elderly patients on peritoneal dialysis exhibit excellent compliance with their treatment regimen and display no increase in the rate of infectious complications though they may have a slight increase in hospital days. They easily achieve adequacy targets, experience good technique survival and their nutritional status is at least as good as that of their hemodialysis counterparts. Patient survival varies around the world but is overall comparable to that of age-matched patients on hemodialysis. Quality of life may be somewhat superior to that of older hemodialysis patients. Elderly patients with end-stage renal disease are appropriate candidates for peritoneal dialysis. It is not medically justifiable to exclude them from consideration for this therapeutic modality.

Management of anaemia in haemodialysis and peritoneal dialysis patients (chapter 8).

PubMed

Richardson, Donald; Hodsman, Alex; van Schalkwyk, Dirk; Tomson, Charlie; Warwick, Graham

2007-08-01

Forty-one percent of UK patients commence RRT with an Hb < 10.0 g/dl. The mean Hb at commencement of RRT is 10.3 g/dl. Eighty-five percent of patients on dialysis in the UK have an Hb > or = 10.0 g/dl by 6 months after commencement of RRT. The median Hb on haemodialysis in the UK is 11.8 g/dl with an IQR of 10.7-12.8 g/dl. Eighty-six percent of haemodialysis patients in the UK have a Hb > or = 10.0 g/dl. The median Hb on peritoneal dialysis in the UK is 12.0 g/dl with an IQR of 11.0-12.9 g/dl. Ninety percent of peritoneal dialysis patients in the UK have an Hb > or = 10.0 g/dl. In the UK, 49% of patients on PD and 48% of patients on haemodialysis have an Hb between 10.5-12.5 g/dl. The median ferritin in UK haemodialysis patients is 413 microg/l (IQR 262-623), 95% of UK haemodialysis patients have a ferritin > or =100 microg/l. The median ferritin in UK PD patients is 256 microg/l (IQR 147-421), 86% of UK peritoneal dialysis patients have a ferritin > or = 100 microg/l. A higher proportion of HD patients than PD patients receive ESA therapy (88% vs 76%). The ESA dose is higher for HD than PD patients (9204 vs 6080 IU/week).

Peritoneal dialysis--experiences.

PubMed

Mirković, Tatjana Durdević

2010-01-01

Peritoneal dialysis is the method of treatment of terminal-stage chronic kidney failure. Nowadays, this method is complementary to haemodialysis. It is based on the principles of the diffusion of solutes and ultrafiltration of fluids across the peritoneal membrane, which acts as a filter. The dialysate is introduced into the peritoneum via the previously positioned peritoneal catheter. The peritoneal dialysis is carried out on daily basis, at home by the patient, and the "exchange" is repeated 4-5 times during the 24 hours. The first steps in peritoneal dialysis at the Department for Haemodialysis of the Clinical Centre of Vojvodina date back to 1973. Until 1992, the patients were subjected to this program only sporadically. Since 1998 the peritoneal dialysis method has been performed at the Clinic for Nephrology and Clinical Immunology. In the period 1998-2008 ninety nine peritoneal catheters were placed. Chronic glomerulonephritis, nephroangiosclerosis and diabetes were identified as the most common causes of chronic renal failure. Two methods of catheter placement were applied: the standard open surgery method (majority of patients) and laparoscopy. Most of the patients were subjected to continuous ambulatory peritoneal dialysis, whereas four patients received automatic dialysis. Transplantation was performed in 10 patients, i.e. cadaveric transplantation and living-related donor transplantation, each in 5 patients. Peritoneal dialysis was available as a service outside our institution as well. A ten-year experience in peritoneal dialysis gained at our Centre has proved the advantages and qualities of this method, strongly supporting its wider application in the treatment of terminal-stage chronic kidney failure.

Peritoneal small solute transport rate is related to the malnutrition inflammation score in peritoneal dialysis patients.

PubMed

Sezer, Siren; Elsurer, Rengin; Afsar, Baris; Arat, Zubeyde; Ozdemir, Nurhan F; Haberal, Mehmet

2007-01-01

A high peritoneal membrane transport status and peritoneal albumin leakage are determinants of morbidity and mortality in patients receiving continuous ambulatory peritoneal dialysis. In this study, we analyzed the relationship between the malnutrition inflammation score, peritoneal transport status, and 24-hour peritoneal albumin leakage in patients receiving peritoneal dialysis. Sixty-six patients receiving peritoneal dialysis (male-female ratio 30/36; age 46.2 +/- 14.1 years; mean duration of peritoneal dialysis 32.4 +/- 23.9 months) who had experienced no attacks of peritonitis within the prior 6 months were included. The malnutrition inflammation score was positively correlated with the serum C-reactive protein concentration, dialysate/plasma creatinine ratio, and 24-hour peritoneal albumin leakage. Triceps and biceps skinfold thicknesses and serum concentrations of prealbumin, total cholesterol, and triglyceride were negatively correlated with the malnutrition inflammation score. Multiple linear regression analysis showed that the malnutrition inflammation score was independently associated with the dialysate/plasma creatinine ratio (p = 0.039) and 24-hour peritoneal albumin amount (p = 0.005). High peritoneal transport status and peritoneal albumin leakage are significantly associated with the malnutrition inflammation score. (c) 2007 S. Karger AG, Basel

Body size and longitudinal body weight changes do not increase mortality in incident peritoneal dialysis patients of the Brazilian peritoneal dialysis multicenter study

PubMed Central

da Silva Fernandes, Natália Maria; Bastos, Marcus Gomes; Franco, Márcia Regina Gianotti; Chaoubah, Alfredo; da Glória Lima, Maria; Divino-Filho, José Carolino; Qureshi, Abdul Rashid

2013-01-01

OBJECTIVES: To determine the roles of body size and longitudinal body weight changes in the survival of incident peritoneal dialysis patients. PATIENTS AND METHODS: Patients (n = 1911) older than 18 years of age recruited from 114 dialysis centers (Dec/2004-Oct/2007) and participating in the Brazilian Peritoneal Dialysis Multicenter Cohort Study were included. Clinical and laboratory data were collected monthly (except if the patient received a transplant, recovered renal function, was transferred to hemodialysis, or died). RESULTS: Survival analyses were performed using Kaplan-Meier survival curves and Cox proportional hazards. Total follow-up was 34 months. The mean age was 59 years (54% female). The weight category percentages were as follows: underweight: 8%; normal: 51%; overweight: 29%; and obese 12%. The multivariate model showed a higher risk of death for a body mass index <18.5 kg/m2, a neutral risk between 25 and 29.9 kg/m2 and a protective effect for an index >30 kg/m2. Patients were divided into five categories according to quintiles of body weight changes during the first year of dialysis: <−3.1%, −3.1 to+0.12%, +0.12 to <+3.1% (reference category), +3.1 to +7.1% and >+7.1%. Patients in the lowest quintile had significantly higher mortality, whereas no negative impact was observed in the other quintiles. CONCLUSION: These findings suggest that overweight/obesity and a positive body weight variation during the first year of peritoneal dialysis therapy do not increase mortality in incident dialysis patients in Brazil. PMID:23420157

Dialysis treatment in patients with rheumatoid arthritis.

PubMed

Hezemans, R L; Krediet, R T; Arisz, L

1995-07-01

The results of dialysis treatment in 24 rheumatoid arthritis patients, 20 chronic rheumatoid arthritis (RA) and 4 juvenile rheumatoid arthritis (JRA), were analysed. Presence of secondary amyloidosis, renal function, morbidity and survival were examined. Amyloidosis was present in 13 patients. Especially among amyloidosis patients, renal function declined rapidly in the last year before dialysis started. On average, 63 days per patient-year were spent in the hospital, 58% was dialysis-related, mainly due to vascular access problems. Hospitalization was even more widespread in amyloidosis patients (79 days, 72% dialysis-related). Median survival in RA patients with amyloidosis was 11 months; in RA patients without amyloidosis this was 29 months. Two-year survival was only 1 out of 10 for the RA amyloidosis patients; for the RA non-amyloidosis patients this was 5 out of 6 (p < 0.01). Cardiovascular causes of death were most frequent. In conclusion, high morbidity and low survival make RA patients with amyloidosis a high-risk group on renal replacement therapy.

Views of Japanese patients on the advantages and disadvantages of hemodialysis and peritoneal dialysis.

PubMed

Nakamura-Taira, Nanako; Muranaka, Yoshimi; Miwa, Masako; Kin, Seikon; Hirai, Kei

2013-08-01

The preference for dialysis modalities is not well understood in Japan. This study explored the subjective views of Japanese patients undergoing dialysis regarding their treatments. The participants were receiving in-center hemodialysis (CHD) or continuous ambulatory peritoneal dialysis (CAPD). In Study 1, 34 participants (17 CHD and 17 CAPD) were interviewed about the advantages and disadvantages of dialysis modalities. In Study 2, 454 dialysis patients (437 CHD and 17 CAPD) rated the advantages and disadvantages of CHD and CAPD in a cross-sectional survey. Interviews showed that professional care and dialysis-free days were considered as advantages of CHD, while independence, less hospital visits, and flexibility were considered as advantages of CAPD. Disadvantages of CHD included restriction of food and fluids and unpleasant symptoms after each dialysis session. Catheter care was an additional disadvantage of CAPD. Survey showed that the highly ranked advantages were professional care in CHD and less frequent hospital visits in CAPD, while the highly ranked disadvantages were concerns about emergency and time restrictions in CHD, and catheter care and difficulty in soaking in a bath in CAPD. The total scores of advantages and disadvantages showed that CHD patients subjectively rated their own modality better CHD over CAPD, while CAPD patients had the opposite opinion. The results of this study indicate that the factors affecting the decision-making process of Japanese patients are unique to Japanese culture, namely considering the trouble caused to the people around patients (e.g., families, spouses, and/or caregivers).

Effects of dialyzer membrane on serum albumin levels in patients receiving hemodialysis.

PubMed

Rault, R M

2003-11-01

Biocompatibility of the dialyzer membrane has been thought to affect the nutritional status in patients receiving chronic hemodialysis. In a series of patients treated in an outpatient dialysis unit, serum albumin was measured before and after changing the dialyzer membrane from one of cellulose to one of polysulfone. There were 48 patients (25 men and 23 women) who had been on dialysis for a mean duration of 78.6 months. The follow-up period was at least 6 months for each type of membrane. Delivered dose of dialysis was higher using the polysulfone membrane but serum albumin was not affected by a change to the more biocompatible membrane. Nutritional considerations are not important in choosing a membrane for dialysis.

Efficacy and safety of the H1N1 monovalent vaccine in renal-transplant recipients and dialysis patients.

PubMed

Beaudreuil, Séverine; Krivine, Anne; Hebibi, Hadia; Ducot, Béatrice; Mazet, Anne-Aurélie; Taouffik, Yacine; Seidowsky, Alexandre; Jacquet, Antoine; Lorenzo, Hans Kristian; Charpentier, Bernard; Francois, Hélène; Durrbach, Antoine

2011-08-01

The (H1N)1v influenza virus infection emerged in 2009 as a serious disease in targeted populations. Herein, we report on the tolerability and efficacy of (anti-H1N1)v vaccination in dialysis and transplant patients. 18 renal-transplant recipients (RTR) and 19 dialysis patients (DP) [12 patients treated with peritoneal dialysis (PDP), 7 patients treated with haemodialysis (HDP)] were enrolled. DPs received one monovalent H1N1 adjuvanted-vaccine injection, and RTRs received two unadjuvanted vaccine injections within a 21-day period. Serologic response was defined as a haemagglutination inhibition titre of > 40 (seroprotection) and/or at least a four-fold increase in antibody titre from baseline (seroconversion). Seroprotection rate after vaccination was greater in DPs than RTRs (p = 0.007), as was seroconversion (p = 0.001). Serologic response was similar in PDPs and HDPs. Serologic response was satisfactory in DPs, whichever dialysis mode (DPD or HDP). It was low in RTRs as compared to DPs.

Risk of dementia in peritoneal dialysis patients compared with hemodialysis patients.

PubMed

Wolfgram, Dawn F; Szabo, Aniko; Murray, Anne M; Whittle, Jeff

2015-01-01

Compared with similarly aged controls, patients with end-stage renal disease (ESRD) have a higher prevalence of cognitive impairment and more rapid cognitive decline, which is not explained by traditional risk factors alone. Since previous small studies suggest an association of cognitive impairment with dialysis modality, we compared incident dementia among patients initiating hemodialysis (HD) vs peritoneal dialysis (PD) in a large national cohort. This is a retrospective cohort study of incident dialysis patients in the United States from 2006 to 2008 with no diagnosis of dementia prior to beginning dialysis. We evaluated the effect of initial dialysis modality on incidence of dementia, diagnosed by Medicare claims data, adjusted for baseline demographic and clinical data from the USRDS registry. Our analysis included 121,623 patients, of whom 8,663 initiated dialysis on PD. The mean age of our cohort was 69.2 years. Patients who initiated PD had a lower cumulative incidence of dementia than those who initiated HD (1.0% vs 2.7%, 2.5% vs 5.3%, and 3.9% vs 7.3% at 1, 2, and 3 years, respectively). The risk of dementia for patients who started on PD was lower compared with those who started on HD, with a hazard ratio (HR) = 0.46 [0.41, 0.53], in an unadjusted model and HR 0.74 [0.64, 0.86] in a matched model. Dialysis modality is associated with incident dementia in a cohort of older ESRD patients. This finding warrants further investigation of the effect of dialysis modality on cognitive function and evaluation for possible mechanisms. Copyright © 2015 International Society for Peritoneal Dialysis.

Determinants of Regret in Elderly Dialysis Patients.

PubMed

Tan, Edlyn Gui Fang; Teo, Irene; Finkelstein, Eric A; Chan, Choong Meng

2018-05-07

In Singapore, most elderly end stage renal disease (ESRD) patients choose dialysis over palliative management. However, dialysis may not be the optimal treatment option given only moderate survival benefits and high costs and treatment burden compared to non-dialysis management. Elderly patients may therefore come to regret this decision. This study investigated (1) extent of patients' decision regret after starting dialysis, and (2) potentially modifiable predictors of regret: satisfaction with chronic kidney disease education, decisional conflict, and decision-making involvement. Cross-sectional study of 103 dialysis patients above 70 years old surveyed at Singapore General Hospital's renal medicine clinics between March and June 2017. Participants reported their levels of decision regret on the Decision Regret Scale (DRS), retrospective decisional conflict on the Decisional Conflict Scale, information satisfaction, and decision-making involvement. 81% of participants reported no decision regret (DRS score <50), 11% ambivalence (DRS =50), and 8% regret (DRS >50). In individual DRS items, 19% felt dialysis had done them harm and 16% would not make the same decision again. In multivariable analyses, lower information satisfaction [b = -0.07 (95% CI: -0.13, -0.01)] and decisional conflict [b = 0.004 (95% CI: 0.002, 0.006)] were significantly associated with decision regret. Although majority of elderly dialysis patients were comfortable with their decision to start dialysis, a proportion was ambivalent or regretted this choice. Regret was more likely among those who experienced decisional conflict and/or expressed poorer information satisfaction. Healthcare professionals should recognize these risk factors and take steps to minimize chances of regret among this population subset. This article is protected by copyright. All rights reserved.

Assessing the impact of budget controls on the prescribing behaviours of physicians treating dialysis-dependent patients.

PubMed

Chang, Ray-E; Tsai, Ya-Hsing; Myrtle, Robert C

2015-11-01

This study examined whether outpatient haemodialysis providers changed their treatment practices with the establishment of an outpatient dialysis global budget (ODGB) through analysing the outpatient visits and medication received by those patients. A sample of 4668 observations (patient year) of 1350 haemodialysis with hypertension (HH) patients and 4668 observations of 1436 non-HH (NHH) patients were drawn from the National Health Insurance Research Database over the years from 1999 to 2005. The impact of ODGB on hypertension-related outpatient utilization of HH was estimated using the difference in difference (DID) method and examined in three stages: (1) the fee for service stage, the pre-ODGB (2000), (2) the phase-in stage (2001-2002) and (3) the post-ODGB stage (2003-2005). ODGB implementation did not affect the number of dialysis visits for HH patients. However, it did lead to a reduction in fees for antihypertension drugs used by haemodialysis facilities. There was an increase of 4.06 visits per patient per year (P < 0.001) in the number of non-dialysis outpatient with antihypertensive drugs visits for HH patients compared with the control group. The total fees for antihypertensive drugs for HH patients increased by New Taiwan Dollars (NT$)13 008 (P < 0.001) per patient per year relative to the control group after the implementation of ODGB. As ODGB was implemented, HH patients received fewer antihypertensive drugs during their dialysis visit. In addition, there was an increase in the number of non-dialysis outpatient visits by HH patients as well as increased payment in the drugs associated with their non-dialysis outpatient visits compared with the control group. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.

Setting Research Priorities for Patients on or Nearing Dialysis

PubMed Central

Hemmelgarn, Brenda; Lillie, Erin; Dip, Sally Crowe P.G.; Cyr, Annette; Gladish, Michael; Large, Claire; Silverman, Howard; Toth, Brenda; Wolfs, Wim; Laupacis, Andreas

2014-01-01

With increasing emphasis among health care providers and funders on patient-centered care, it follows that patients and their caregivers should be included when priorities for research are being established. This study sought to identify the most important unanswered questions about the management of kidney failure from the perspective of adult patients on or nearing dialysis, their caregivers, and the health care professionals who care for these patients. Research uncertainties were identified through a national Canadian survey of adult patients on or nearing dialysis, their caregivers, and health care professionals. Uncertainties were refined by a steering committee that included patients, caregivers, researchers, and clinicians to assemble a short-list of the top 30 uncertainties. Thirty-four people (11 patients; five caregivers; eight physicians; six nurses; and one social worker, pharmacist, physiotherapist, and dietitian each) from across Canada subsequently participated in a workshop to determine the top 10 research questions. In total, 1570 usable research uncertainties were received from 317 respondents to the survey. Among these, 259 unique uncertainties were identified; after ranking, these were reduced to a short-list of 30 uncertainties. During the in-person workshop, the top 10 research uncertainties were identified, which included questions about enhanced communication among patients and providers, dialysis modality options, itching, access to kidney transplantation, heart health, dietary restrictions, depression, and vascular access. These can be used alongside the results of other research priority–setting exercises to guide researchers in designing future studies and inform health care funders. PMID:24832095

High fall incidence and fracture rate in elderly dialysis patients.

PubMed

Polinder-Bos, H A; Emmelot-Vonk, M H; Gansevoort, R T; Diepenbroek, A; Gaillard, C A J M

2014-12-01

Although it is recognised that the dialysis population is ageing rapidly, geriatric complications such as falls are poorly appreciated, despite the many risk factors for falls in this population. The objective of this study was to determine the incidence, complications and risk factors for falls in an elderly dialysis population. A one-year observational study of chronic dialysis patients aged ≥ 70 years. At baseline, patient characteristics were noted and during follow-up the vital parameters and laboratory values were recorded. Patients were questioned weekly about falls, fall circumstances and consequences by trained nurses. 49 patients were included with a median age of 79.3 years (70-89 years). During follow-up 40 fall accidents occurred in 27 (55%) patients. Falls resulted in fractures in 15% of cases and in hospital admissions in 15%. In haemodialysis (HD) patients, the mean systolic blood pressure (SBP) before HD was lower in fallers compared with non-fallers (130 vs. 143 mmHg). Several patients in the lower blood pressure category received antihypertensive medication. For every 5 mmHg lower SBP (before HD) the fall risk increased by 30% (hazard ratio (HR) 1.30, 95% CI 1.03-1.65, p = 0.03). Furthermore, fall risk increased by 22% for every 10 pmol/l rise of parathyroid hormone (HR 1.22, 95% CI 1.06-1.39, p = 0.004). Elderly dialysis patients have a high incidence of falls accompanied by a high fracture rate. Given the high complication rate, elderly patients at risk of falling should be identified and managed. Reduction of blood pressure-lowering medication might be a treatment strategy to reduce falls.

Early Dialysis and Adverse Outcomes After Hurricane Sandy.

PubMed

Lurie, Nicole; Finne, Kristen; Worrall, Chris; Jauregui, Maria; Thaweethai, Tanayott; Margolis, Gregg; Kelman, Jeffrey

2015-09-01

Hemodialysis patients have historically experienced diminished access to care and increased adverse outcomes after natural disasters. Although "early dialysis" in advance of a storm is promoted as a best practice, evidence for its effectiveness as a protective measure is lacking. Building on prior work, we examined the relationship between the receipt of dialysis ahead of schedule before the storm (also known as early dialysis) and adverse outcomes of patients with end-stage renal disease in the areas most affected by Hurricane Sandy. Retrospective cohort analysis, using claims data from the Centers for Medicare & Medicaid Services Datalink Project. Patients receiving long-term hemodialysis in New York City and the state of New Jersey, the areas most affected by Hurricane Sandy. Receipt of early dialysis compared to their usual treatment pattern in the week prior to the storm. Emergency department (ED) visits, hospitalizations, and 30-day mortality following the storm. Of 13,836 study patients, 8,256 (60%) received early dialysis. In unadjusted logistic regression models, patients who received early dialysis were found to have lower odds of ED visits (OR, 0.75; 95% CI, 0.63-0.89; P=0.001) and hospitalizations (OR, 0.77; 95% CI, 0.65-0.92; P=0.004) in the week of the storm and similar odds of 30-day mortality (OR, 0.80; 95% CI, 0.58-1.09; P=0.2). In adjusted multivariable logistic regression models, receipt of early dialysis was associated with lower odds of ED visits (OR, 0.80; 95% CI, 0.67-0.96; P=0.01) and hospitalizations (OR, 0.79; 95% CI, 0.66-0.94; P=0.01) in the week of the storm and 30-day mortality (OR, 0.72; 95% CI, 0.52-0.997; P=0.048). Inability to determine which patients were offered early dialysis and declined and whether important unmeasured patient characteristics are associated with receipt of early dialysis. Patients who received early dialysis had significantly lower odds of having an ED visit and hospitalization in the week of the storm and of

Patient perspectives on informed decision-making surrounding dialysis initiation

PubMed Central

Song, Mi-Kyung; Lin, Feng-Chang; Gilet, Constance A.; Arnold, Robert M.; Bridgman, Jessica C.; Ward, Sandra E.

2013-01-01

Background Careful patient–clinician shared decision-making about dialysis initiation has been promoted, but few studies have addressed patient perspectives on the extent of information provided and how decisions to start dialysis are made. Methods Ninety-nine maintenance dialysis patients recruited from 15 outpatient dialysis centers in North Carolina completed semistructured interviews on information provision and communication about the initiation of dialysis. These data were examined with content analysis. In addition, informed decision-making (IDM) scores were created by summing patient responses (yes/no) to 10 questions about the decision-making. Results The mean IDM score was 4.4 (of 10; SD = 2.0); 67% scored 5 or lower. Age at the time of decision-making (r = −0.27, P = 0.006), years of education (r = 0.24, P = 0.02) and presence of a warning about progressing to end-stage kidney disease (t = 2.9, P = 0.005) were significantly associated with IDM scores. Nearly 70% said that the risks and burdens of dialysis were not mentioned at all, and only one patient recalled that the doctor offered the option of not starting dialysis. While a majority (67%) said that they felt they had no choice about starting dialysis (because the alternative would be death) or about dialysis modality, only 21.2% said that they had felt rushed to make a decision. About one-third of the patients perceived that the decision to start dialysis and modality was already made by the doctor. Conclusions A majority of patients felt unprepared and ill-informed about the initiation of dialysis. Improving the extent of IDM about dialysis may optimize patient preparation prior to starting treatment and their perceptions about the decision-making process. PMID:23901048

Estimating residual kidney function in dialysis patients without urine collection

PubMed Central

Shafi, Tariq; Michels, Wieneke M.; Levey, Andrew S.; Inker, Lesley A.; Dekker, Friedo W.; Krediet, Raymond T.; Hoekstra, Tiny; Schwartz, George J.; Eckfeldt, John H.; Coresh, Josef

2016-01-01

Residual kidney function contributes substantially to solute clearance in dialysis patients but cannot be assessed without urine collection. We used serum filtration markers to develop dialysis-specific equations to estimate urinary urea clearance without the need for urine collection. In our development cohort, we measured 24-hour urine clearances under close supervision in 44 patients and validated these equations in 826 patients from the Netherlands Cooperative Study on the Adequacy of Dialysis. For the development and validation cohorts, median urinary urea clearance was 2.6 and 2.4 mL/min, respectively. During the 24-hour visit in the development cohort, serum β-trace protein concentrations remained in steady state but concentrations of all other markers increased. In the validation cohort, bias (median measured minus estimated clearance) was low for all equations. Precision was significantly better for β-trace protein and β2-microglobulin equations and the accuracy was significantly greater for β-trace protein, β2-microglobulin and cystatin C equations, compared with the urea plus creatinine equation. Area under the receiver operator characteristic curve for detecting measured urinary urea clearance by equation-estimated urinary urea clearance (both 2 mL/min or more) were 0.821, 0.850 and 0.796 for β-trace protein, β2-microglobulin and cystatin C equations, respectively; significantly greater than the 0.663 for the urea plus creatinine equation. Thus, residual renal function can be estimated in dialysis patients without urine collections. PMID:26924062

Sevelamer hydrochloride in peritoneal dialysis patients: results of a multicenter cross-sectional study.

PubMed

Ramos, Rosa; Moreso, Francesc; Borras, Mercè; Ponz, Esther; Buades, Joan M; Teixidó, Josep; Morey, Antoni; Garcia, Carme; Vera, Manel; Doñate, M Teresa; de Arellano, Manuel Ramírez; Barbosa, Francesc; González, M Teresa

2007-01-01

Sevelamer hydrochloride is a phosphate binder widely employed in hemodialysis patients. Until now, information about its efficacy and safety in peritoneal dialysis patients has been scarce. In September 2005 a cross-sectional study of demographic, biochemical, and therapeutic data of patients from 10 peritoneal dialysis units in Catalonia and the Balearic Islands, Spain, was conducted. We analyzed data from 228 patients. At the time of the study, 128 patients (56%) were receiving sevelamer. Patients receiving sevelamer were younger (p < 0.01), showed a longer period of time on dialysis (p < 0.01), and had a lower Charlson Comorbidity Index (p < 0.01). Serum calcium and intact parathyroid hormone levels were not different between the two groups, while phosphate levels <5.5 mg/dL were observed more frequently in patients not receiving sevelamer (79% vs 61%, p < 0.01). Serum total cholesterol (167 +/- 41 vs 189 +/- 42 mg/dL, p < 0.01) and low density lipoprotein (LDL) cholesterol (90 +/- 34 vs 109 +/- 34 mg/dL, p < 0.01), but not high density lipoprotein cholesterol or triglycerides, were lower in sevelamer-treated patients. Moreover, sevelamer-treated patients displayed a higher serum albumin (38 +/- 5 vs 36 +/- 4 g/L, p < 0.01) and a lower C-reactive protein (4.9 +/- 12.8 vs 8.8 +/- 15.7 mg/L, p < 0.01). Blood bicarbonate levels <22 mmol/L were observed more frequently in patients receiving sevelamer (22% vs 5%, p < 0.01). Logistic regression analysis adjusting by confounding variables confirmed that sevelamer therapy was associated with serum total cholesterol <200 mg/dL [relative risk (RR): 2.77, 95% confidence interval (CI): 1.44 - 5.26, p = 0.002] and blood bicarbonate <22 mmol/L (RR: 8.5, 95% CI: 2.6 - 27.0, p < 0.001), but not with serum phosphate >5.5 mg/dL, calcium-phosphate product >55 mg(2)/dL(2), serum albumin <35 g/L, or C-reactive protein >5 mg/L. This uncontrolled cross-sectional study in peritoneal dialysis patients showed that sevelamer hydrochloride

A Comparison of the Regional Circulation in the Feet between Dialysis and Non-Dialysis Patients using Indocyanine Green Angiography.

PubMed

Nishizawa, M; Igari, K; Kudo, T; Toyofuku, T; Inoue, Y; Uetake, H

2017-09-01

Peripheral artery disease in dialysis cases is more prone to critical limb ischemia compared to non-dialysis cases, with a significantly high rate of major amputation of the lower limbs. Lesions are distributed on the more distal side in dialysis critical limb ischemia cases. The aim of this study was to investigate the usefulness of indocyanine green angiography to determine differences in the regional circulation in the foot between dialysis and non-dialysis patients. The subjects included 62 cases, among which 20 were dialysis patients and 42 were non-dialysis patients. We compared the indocyanine green angiography parameters for regions of interest in the dialysis and non-dialysis groups, which included the magnitude of intensity from indocyanine green onset to maximum intensity (Imax), the time from indocyanine green onset to maximum intensity (Tmax), the time elapsed from the fluorescence onset to half the maximum intensity (T1/2), and the time from maximum intensity to declining to 90% of the maximum intensity (Td90%). These indocyanine green angiography parameters were measured at region of interest 1 (the Chopart joint), region of interest 2 (the Lisfranc joint), and region of interest 3 (the distal region of the first metatarsal bone). In the comparison between the dialysis and non-dialysis groups, a significant difference was observed regarding Tmax, T1/2, and Td90%, especially in region of interest 3. In this study, we show that regional tissue perfusion is more deteriorated in dialysis patients compared with non-dialysis patients using indocyanine green angiography. Tmax, T1/2, and Td90% could be useful clinical parameters to compare ischemic severity of the lower limb between dialysis and non-dialysis patients.

One-Year Linear Trajectories of Symptoms, Physical Functioning, Cognitive Functioning, Emotional Well-being, and Spiritual Well-being Among Patients Receiving Dialysis.

PubMed

Song, Mi-Kyung; Paul, Sudeshna; Ward, Sandra E; Gilet, Constance A; Hladik, Gerald A

2018-01-25

This study evaluated 1-year linear trajectories of patient-reported dimensions of quality of life among patients receiving dialysis. Longitudinal observational study. 227 patients recruited from 12 dialysis centers. Sociodemographic and clinical characteristics. Participants completed an hour-long interview monthly for 12 months. Each interview included patient-reported outcome measures of overall symptoms (Edmonton Symptom Assessment System), physical functioning (Activities of Daily Living/Instrumental Activities of Daily Living), cognitive functioning (Patient's Assessment of Own Functioning Inventory), emotional well-being (Center for Epidemiologic Studies Depression Scale, State Anxiety Inventory, and Positive and Negative Affect Schedule), and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale). For each dimension, linear and generalized linear mixed-effects models were used. Linear trajectories of the 5 dimensions were jointly modeled as a multivariate outcome over time. Although dimension scores fluctuated greatly from month to month, overall symptoms, cognitive functioning, emotional well-being, and spiritual well-being improved over time. Older compared with younger participants reported higher scores across all dimensions (all P<0.05). Higher comorbidity scores were associated with worse scores in most dimensions (all P<0.01). Nonwhite participants reported better spiritual well-being compared with their white counterparts (P<0.01). Clustering analysis of dimension scores revealed 2 distinctive clusters. Cluster 1 was characterized by better scores than those of cluster 2 in nearly all dimensions at baseline and by gradual improvement over time. Study was conducted in a single region of the United States and included mostly patients with high levels of function across the dimensions of quality of life studied. Multidimensional patient-reported quality of life varies widely from month to month regardless of

Setting research priorities for patients on or nearing dialysis.

PubMed

Manns, Braden; Hemmelgarn, Brenda; Lillie, Erin; Dip, Sally Crowe P G; Cyr, Annette; Gladish, Michael; Large, Claire; Silverman, Howard; Toth, Brenda; Wolfs, Wim; Laupacis, Andreas

2014-10-07

With increasing emphasis among health care providers and funders on patient-centered care, it follows that patients and their caregivers should be included when priorities for research are being established. This study sought to identify the most important unanswered questions about the management of kidney failure from the perspective of adult patients on or nearing dialysis, their caregivers, and the health care professionals who care for these patients. Research uncertainties were identified through a national Canadian survey of adult patients on or nearing dialysis, their caregivers, and health care professionals. Uncertainties were refined by a steering committee that included patients, caregivers, researchers, and clinicians to assemble a short-list of the top 30 uncertainties. Thirty-four people (11 patients; five caregivers; eight physicians; six nurses; and one social worker, pharmacist, physiotherapist, and dietitian each) from across Canada subsequently participated in a workshop to determine the top 10 research questions. In total, 1570 usable research uncertainties were received from 317 respondents to the survey. Among these, 259 unique uncertainties were identified; after ranking, these were reduced to a short-list of 30 uncertainties. During the in-person workshop, the top 10 research uncertainties were identified, which included questions about enhanced communication among patients and providers, dialysis modality options, itching, access to kidney transplantation, heart health, dietary restrictions, depression, and vascular access. These can be used alongside the results of other research priority-setting exercises to guide researchers in designing future studies and inform health care funders. Copyright © 2014 by the American Society of Nephrology.

Patient-Staff Interactions and Mental Health in Chronic Dialysis Patients

ERIC Educational Resources Information Center

Swartz, Richard D.; Perry, Erica; Brown, Stephanie; Swartz, June; Vinokur, Amiram

2008-01-01

Chronic dialysis imposes ongoing stress on patients and staff and engenders recurring contact and long-term relationships. Thus, chronic dialysis units are opportune settings in which to investigate the impact of patients' relationships with staff on patient well-being. The authors designed the present study to examine the degree to which…

Is Dialysis Modality a Factor in the Survival of Patients Initiating Dialysis After Kidney Transplant Failure?

PubMed Central

Perl, Jeffrey; Dong, James; Rose, Caren; Jassal, Sarbjit Vanita; Gill, John S.

2013-01-01

♦ Background: Kidney transplant failure (TF) is among the leading causes of dialysis initiation. Whether survival is similar for patients treated with peritoneal dialysis (PD) and with hemodialysis (HD) after TF is unclear and may inform decisions concerning dialysis modality selection. ♦ Methods: Between 1995 and 2007, 16 113 adult dialysis patients identified from the US Renal Data System initiated dialysis after TF. A multivariable Cox proportional hazards model was used to evaluate the impact of initial dialysis modality (1 865 PD, 14 248 HD) on early (1-year) and overall mortality in an intention-to-treat approach. ♦ Results: Compared with HD patients, PD patients were younger (46.1 years vs 49.4 years, p < 0.0001) with fewer comorbidities such as diabetes mellitus (23.1% vs 25.7%, p < 0.0001). After adjustment, survival among PD patients was greater within the first year after dialysis initiation [adjusted hazard ratio (AHR): 0.85; 95% confidence interval (CI): 0.74 to 0.97], but lower after 2 years (AHR: 1.15; 95% CI: 1.02 to 1.29). During the entire period of observation, survival in both groups was similar (AHR for PD compared with HD: 1.09; 95% CI: 1.0 to 1.20). In a sensitivity analysis restricted to a cohort of 1865 propensity-matched pairs of HD and PD patients, results were similar (AHR: 1.03; 95% CI: 0.93 to 1.14). Subgroups of patients with a body mass index exceeding 30 kg/m2 [AHR: 1.26; 95% CI: 1.05 to 1.52) and with a baseline estimated glomerular filtration rate (eGFR) less than 5 mL/min/1.73 m2 (AHR: 1.45; 95% CI: 1.05 to 1.98) experienced inferior overall survival when treated with PD. ♦ Conclusions: Compared with HD, PD is associated with an early survival advantage, inferior late survival, and similar overall survival in patients initiating dialysis after TF. Those data suggest that increased initial use of PD among patients returning to dialysis after TF may be associated with improved outcomes, except among patients with a higher

Timing of dialysis initiation in transplant-naive and failed transplant patients

PubMed Central

Molnar, Miklos Z.; Ojo, Akinlolu O.; Bunnapradist, Suphamai; Kovesdy, Csaba P.; Kalantar-Zadeh, Kamyar

2017-01-01

Over the past two decades, most guidelines have advocated early dialysis initiation on the basis of studies showing improved survival in patients starting dialysis early. These recommendations led to an increase in the proportion of patients initiating dialysis with an estimated glomerular filtration rate (eGFR) >10 ml/min/1.73 m2, from 20% in 1996 to 52% in 2008. During this period, patients starting dialysis with an eGFR ≥15 ml/min/1.73 m2 increased from 4% to 17%. However, recent studies have failed to substantiate a benefit of early dialysis initiation and some data have suggested worse outcomes in patients starting dialysis with a higher eGFR. Several reasons for this seemingly paradoxical observation have been suggested, including the fact that patients requiring early dialysis are likely to have more severe symptoms and comorbidities, leading to confounding by indication, as well as biological mechanisms that causally relate early dialysis therapy to adverse outcomes. Dialysis reinitiation in patients with a failing renal allograft encounters similar problems. However, unique factors associated with a failed allograft means that the optimal timing of dialysis initiation in failed transplant patients might differ from that in transplant-naive patients. In this Review, we will discuss studies of dialysis initiation and compare risks and benefits of early versus late dialysis therapy. PMID:22371250

Pro: Higher serum bicarbonate in dialysis patients is protective.

PubMed

Misra, Madhukar

2016-08-01

Chronic metabolic acidosis is common in dialysis patients. Bicarbonate administration via the dialysate helps maintain the acid-base balance in these patients. Serum bicarbonate level in dialysis patients is determined by several factors that include dietary protein intake, nutritional status and dialysis prescription, etc. Additionally, a meaningful interpretation of serum bicarbonate in dialysis patients requires an understanding of complexities involving its measurement. Both very low as well very high levels of serum bicarbonate have been associated with adverse outcomes in observational studies. However, recent observational data, when adjusted for the confounding effects of nutritional status, do not associate higher predialysis serum bicarbonate with adverse consequences. At this time, there are no prospective studies available that have examined the association of serum bicarbonate with hard outcomes in dialysis patients. The ideal level of serum bicarbonate in dialysis patients is therefore unknown. This article examines the available data with regard to the benefits of higher predialysis serum bicarbonate. © The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Estimating residual kidney function in dialysis patients without urine collection.

PubMed

Shafi, Tariq; Michels, Wieneke M; Levey, Andrew S; Inker, Lesley A; Dekker, Friedo W; Krediet, Raymond T; Hoekstra, Tiny; Schwartz, George J; Eckfeldt, John H; Coresh, Josef

2016-05-01

Residual kidney function contributes substantially to solute clearance in dialysis patients but cannot be assessed without urine collection. We used serum filtration markers to develop dialysis-specific equations to estimate urinary urea clearance without the need for urine collection. In our development cohort, we measured 24-hour urine clearances under close supervision in 44 patients and validated these equations in 826 patients from the Netherlands Cooperative Study on the Adequacy of Dialysis. For the development and validation cohorts, median urinary urea clearance was 2.6 and 2.4 ml/min, respectively. During the 24-hour visit in the development cohort, serum β-trace protein concentrations remained in steady state but concentrations of all other markers increased. In the validation cohort, bias (median measured minus estimated clearance) was low for all equations. Precision was significantly better for β-trace protein and β2-microglobulin equations and the accuracy was significantly greater for β-trace protein, β2-microglobulin, and cystatin C equations, compared with the urea plus creatinine equation. Area under the receiver operator characteristic curve for detecting measured urinary urea clearance by equation-estimated urinary urea clearance (both 2 ml/min or more) were 0.821, 0.850, and 0.796 for β-trace protein, β2-microglobulin, and cystatin C equations, respectively; significantly greater than the 0.663 for the urea plus creatinine equation. Thus, residual renal function can be estimated in dialysis patients without urine collections. Copyright © 2016 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.

Hypertension and cardiovascular risk assessment in dialysis patients.

PubMed

Locatelli, Francesco; Covic, Adrian; Chazot, Charles; Leunissen, Karel; Luño, José; Yaqoob, Mohammed

2004-05-01

Cardiovascular (CV) disease is the main cause of morbidity and mortality in dialysis patients. Hypertension in patients affected by chronic renal insufficiency (CRI) has been recognized as one of the major classical CV risk factors in CRI from the very beginning of the dialysis era. However, its treatment is still unsatisfactory. A discussion is employed to achieve a consensus on key points relating to the epidemiological, pathophysiological and clinical characteristics of hypertension in renal patients, in the light of global CV risk assessment. CV disease is accelerated by CRI, in particular by uraemia-specific risk factors. This is reflected by the fact that general population-based equations for calculating CV risk underestimate the real CV risk in CRI and dialysis patients. Hypertension in dialysis patients is clearly a major CV risk factor. Isolated systolic hypertension with increased pulse pressure is the most prevalent blood pressure (BP) anomaly in dialysis patients, due to stiffening of the arterial tree. BP should be assessed by clinical measurements on a routine basis, leaving 24 h monitoring for selected cases. The targets of BP control should be those recommended by the present guidelines, i.e. <140/90 mmHg, or the lowest possible values that are well tolerated. The pathophysiological cornerstone of hypertension in dialysis patients is extra-cellular volume expansion, which is typically sodium-sensitive, given the loss of renal function. Therefore, the principles of hypertension treatment in dialysis are an achievement of dry body weight, proper dialysis prescription with respect to dialysis time and intra-dialytic sodium balance, and dietary sodium and water restriction. Pharmacological treatment should only be the second option, after the adequate and complete application of all other means. No comparative pharmacological trials have specifically addressed the issue of hypertension control in dialysis patients. Therefore, this workshop group had to

Parathyroid Hormone and Bone in Dialysis Patients.

PubMed

Kazama, Junichiro James; Wakasugi, Minako

2018-06-01

Bone maintains extracellular calcium levels through a system called bone remodeling. Parathyroid hormone (PTH) is the major initiator of this system, which is secreted by the information through calcium sensing receptor in parathyroid cells. PTH modifies calcified bone morphology through a process of its bone action. Therefore, extremely hyperactivated parathyroid function seen in patients with chronic kidney disease has been considered to have a negative impact on the bone mechanical properties. While skeletal deformities and fragility fractures were common among dialysis patients up to the 1970s, after which methods for the treatment of hyperparathyroidism were developed, we now seldom encounter those cases with severe secondary hyperparathyroidism in Japan. In a three-dimensional morphometry of biopsied iliac bone samples obtained from dialysis patients, PTH level was inversely correlated with cortical bone thickness, however, this relationship disappeared among those with intact PTH < 1000 pg/mL. Higher PTH levels were associated with more complicated and irregular cancellous bone surface, but this change was not accompanied with decreased cancellous bone connectivity. These findings theoretically support the recent clinical study results that PTH levels no longer show a tight correlation with fracture risk in dialysis patients. Nevertheless, the use of calcium sensing receptor agonist is likely to be associated with reduced hip fracture risk in dialysis patients. Further study is needed to reveal its pharmacological mechanism on bone. © 2018 The Authors. Therapeutic Apheresis and Dialysis published by John Wiley & Sons Australia, Ltd on behalf of International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.

[Approach to quality objectives in incidents of patients in peritoneal dialysis].

PubMed

Portolés, J; Ocaña, J; López-Sánchez, P; Gómez, M; Rivera, M T; Del Peso, G; Corchete, E; Bajo, M A; Rodríguez-Palomares, J R; Fernández-Perpen, A; López-Gómez, J M

2010-01-01

In 2007 the Scientific Quality-technical and Improvement of Quality in Peritoneal Dialysis was edited. It includes several quality indicators. As far as we know, only some groups of work had evaluated these indicators, with inconclusive results. To study the evolution and impact of guidelines in Peritoneal Dialysis. Prospective cohort study of each incident of patients in Peritoneal Dialysis, in a regional public health care system (2003-2006). We prospectively collected baseline clinical and analytical data, technical efficacy, cardiovascular risk, events and deaths, hospital admissions and also prescription data was collected every 6 months. Over a period of 3 years, 490 patients (53.58 years of age; 61.6% males.) Causes of ERC: glomerular 25.5%, diabetes 16%, vascular 12.4%, and interstitial 13.3%. 26.48% were on the list for transplant. Dialysis efficacy: Of the first available results, the residual renal function was 6.37 ml/min, achieving 67.6% of all the objectives K/DOQI. 38.6% remained within the range during the entire first year. Anaemia: 79.3% received erythropoietic stimulating agents and maintained an average Hb of 12.1 g/dl. The percentage of patients in the range (Hb: 11-13 g/dl) improved after a year (58.4% vs 56.3% keeping in the range during this time of 25.6%). Evolution: it has been estimated that per patient-year the risk of: 1) mortality is 0.06 IC 95% [0.04-0.08]; 2) admissions 0.65 [0.58-0.72]; 3) peritoneal infections 0.5 [0.44-0.56]. Diabetes Mellitus patients had a higher cardiovascular risk and prevalence of events. The degrees of control during the follow-up in many topics of peritoneal dialysis improve each year; however they are far from the recommended guidelines, especially if they are evaluated throughout the whole study.

Incidence and management of dialysis patients with renal calculi.

PubMed

Viterbo, Rosalia; Mydlo, Jack H

2002-01-01

The incidence of renal stones in patients on dialysis, while lower in number compared to the general population because of decreased renal function, is nonetheless a clinical dilemma. We wanted to evaluate the incidence and management of stone disease in patients on hemodialysis. We reviewed the literature from 1966 to the present using Medline. Study inclusion criteria were detection and treatment of stone disease in both hemodialysis and peritoneal dialysis patients. It is estimated that between 5 and 13% of all dialysis patients will develop symptomatic renal calculi and many more asymptomatic calculi. Many of the stone-forming dialysis patients will have recurring stone disease with one study finding an 83.3% recurrence rate. Since dialysis patients have a wide range of urine output, the clinician should be alert to the possibility of stone formation. We recommend yearly ultrasound examinations on all dialysis patients as well as citrate and magnesium supplements with careful follow-up of laboratory results and urine electrolytes. We also recommend careful follow-up of all patients on aluminum-hydroxide phosphate binders as they are predisposed to form Al-Mg-urate stones. For those dialysis patients that form renal calculi, watchful waiting and symptomatic treatment is recommended since almost all patients will spontaneously pass their stones. However, ESWL and other current modalities may be used with no greater morbidity compared to nondialysis cohorts. We also suggest that patients with severe recurring intractable stone disease who are candidates for renal transplantation should be offered bilateral nephrectomies. Copyright 2002 S. Karger AG, Basel

Vitamin K antagonist use and mortality in dialysis patients.

PubMed

Voskamp, Pauline W M; Rookmaaker, Maarten B; Verhaar, Marianne C; Dekker, Friedo W; Ocak, Gurbey

2018-01-01

The risk-benefit ratio of vitamin K antagonists for different CHA2DS2-VASc scores in patients with end-stage renal disease treated with dialysis is unknown. The aim of this study was to investigate the association between vitamin K antagonist use and mortality for different CHA2DS2-VASc scores in a cohort of end-stage renal disease patients receiving dialysis treatment. We prospectively followed 1718 incident dialysis patients. Hazard ratios were calculated for all-cause and cause-specific (stroke, bleeding, cardiovascular and other) mortality associated with vitamin K antagonist use. Vitamin K antagonist use as compared with no vitamin K antagonist use was associated with a 1.2-fold [95% confidence interval (95% CI) 1.0-1.5] increased all-cause mortality risk, a 1.5-fold (95% CI 0.6-4.0) increased stroke mortality risk, a 1.3-fold (95% CI 0.4-4.2) increased bleeding mortality risk, a 1.2-fold (95% CI 0.9-1.8) increased cardiovascular mortality risk and a 1.2-fold (95% CI 0.8-1.6) increased other mortality risk after adjustment. Within patients with a CHA2DS2-VASc score ≤1, vitamin K antagonist use was associated with a 2.8-fold (95% CI 1.0-7.8) increased all-cause mortality risk as compared with no vitamin K antagonist use, while vitamin K antagonist use within patients with a CHA2DS2-VASc score ≥2 was not associated with an increased mortality risk after adjustment. Vitamin K antagonist use was not associated with a protective effect on mortality in the different CHA2DS2-VASc scores in dialysis patients. The lack of knowledge on the indication for vitamin K antagonist use could lead to confounding by indication. © The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Peritoneal Fluid Transport rather than Peritoneal Solute Transport Associates with Dialysis Vintage and Age of Peritoneal Dialysis Patients.

PubMed

Waniewski, Jacek; Antosiewicz, Stefan; Baczynski, Daniel; Poleszczuk, Jan; Pietribiasi, Mauro; Lindholm, Bengt; Wankowicz, Zofia

2016-01-01

During peritoneal dialysis (PD), the peritoneal membrane undergoes ageing processes that affect its function. Here we analyzed associations of patient age and dialysis vintage with parameters of peritoneal transport of fluid and solutes, directly measured and estimated based on the pore model, for individual patients. Thirty-three patients (15 females; age 60 (21-87) years; median time on PD 19 (3-100) months) underwent sequential peritoneal equilibration test. Dialysis vintage and patient age did not correlate. Estimation of parameters of the two-pore model of peritoneal transport was performed. The estimated fluid transport parameters, including hydraulic permeability (LpS), fraction of ultrasmall pores (α u), osmotic conductance for glucose (OCG), and peritoneal absorption, were generally independent of solute transport parameters (diffusive mass transport parameters). Fluid transport parameters correlated whereas transport parameters for small solutes and proteins did not correlate with dialysis vintage and patient age. Although LpS and OCG were lower for older patients and those with long dialysis vintage, αu was higher. Thus, fluid transport parameters--rather than solute transport parameters--are linked to dialysis vintage and patient age and should therefore be included when monitoring processes linked to ageing of the peritoneal membrane.

National Trends in Emergency Room Visits of Dialysis Patients for Adverse Drug Reactions.

PubMed

Chan, Lili; Saha, Aparna; Poojary, Priti; Chauhan, Kinsuk; Naik, Nidhi; Coca, Steven; Garimella, Pranav S; Nadkarni, Girish N

2018-06-12

Various medications are cleared by the kidneys, therefore patients with impaired renal function, especially dialysis patients are at risk for adverse drug events (ADEs). There are limited studies on ADEs in maintenance dialysis patients. We utilized a nationally representative database, the Nationwide Emergency Department Sample, from 2008 to 2013, to compare emergency department (ED) visits for dialysis and propensity matched non-dialysis patients. Log binomial regression was used to calculate relative risk of hospital admission and logistic regression to calculate ORs for in-hospital mortality while adjusting for patient and hospital characteristics. While ED visits for ADEs decreased in both groups, they were over 10-fold higher in dialysis patients than non-dialysis patients (65.8-88.5 per 1,000 patients vs. 4.6-5.4 per 1,000 patients respectively, p < 0.001). The top medication category associated with ED visits for ADEs in dialysis patients is agents primarily affecting blood constituents, which has increased. After propensity matching, patient admission was higher in dialysis patients than non-dialysis patients, (88 vs. 76%, p < 0.001). Dialysis was associated with a 3% increase in risk of admission and 3 times the odds of in-hospital mortality (adjusted OR 3, 95% CI 2.7-2.3.3). ED visits for ADEs are substantially higher in dialysis patients than non-dialysis patients. In dialysis patients, ADEs associated with agents primarily affecting blood constituents are on the rise. ED visits for ADEs in dialysis patients have higher inpatient admissions and in-hospital mortality. Further studies are needed to identify and implement measures aimed at reducing ADEs in dialysis patients. © 2018 S. Karger AG, Basel.

Outcomes in patients with chronic kidney disease not on dialysis receiving extended dosing regimens of darbepoetin alfa: long-term results of the EXTEND observational cohort study.

PubMed

Galle, Jan-Christoph; Addison, Janet; Suranyi, Michael G; Claes, Kathleen; Di Giulio, Salvatore; Guerin, Alain; Herlitz, Hans; Kiss, István; Farouk, Mourad; Manamley, Nick; Wirnsberger, Gerhard; Winearls, Christopher

2016-12-01

Extended dosing of the erythropoiesis-stimulating agent (ESA) darbepoetin alfa (DA) once biweekly or monthly reduces anaemia treatment burden. This observational study assessed outcomes and dosing patterns in patients with chronic kidney disease not on dialysis (CKD-NoD) commencing extended dosing of DA. Adult CKD-NoD patients starting extended dosing of DA in Europe or Australia in June 2006 or later were followed up until December 2012. Outcomes included haemoglobin (Hb) concentration, ESA dosing, mortality rates and receipt of dialysis and renal transplantation. Subgroup analyses were conducted for selected outcomes. Of 6035 enrolled subjects, 5723 (94.8%) met analysis criteria; 1795 (29.7%) received dialysis and 238 (3.9%) underwent renal transplantation. Mean (standard deviation) Hb concentration at commencement of extended dosing was 11.0 (1.5) g/dL. Mean [95% confidence interval (CI)] Hb 12 months after commencement of extended dosing (primary outcome) was 11.6 g/dL (11.5, 11.6) overall and was similar across countries, with no differences between subjects previously treated with an ESA versus ESA-naïve subjects, subjects with versus without prior renal transplant or diabetics versus non-diabetics. Weekly ESA dose gradually decreased following commencement of extended DA dosing and was similar across subgroups. The decrease in weekly DA dose was accompanied by an increase in the proportion of patients receiving iron therapy. Hb concentrations declined following changes in ESA labels and treatment guidelines. The mortality rate (95% CI) was 7.06 (6.68, 7.46) deaths per 100 years of follow-up. Subjects alive at study end had stable Hb concentrations in the preceding year, while those who died had lower and declining Hb concentrations in their last year. Long-term, extended dosing of DA maintained Hb concentrations in patients already treated with an ESA and corrected and maintained Hb in ESA-naïve patients. © The Author 2016. Published by Oxford University

Outcomes in patients with chronic kidney disease not on dialysis receiving extended dosing regimens of darbepoetin alfa: long-term results of the EXTEND observational cohort study

PubMed Central

Galle, Jan-Christoph; Addison, Janet; Suranyi, Michael G.; Claes, Kathleen; Di Giulio, Salvatore; Guerin, Alain; Herlitz, Hans; Kiss, István; Farouk, Mourad; Manamley, Nick; Wirnsberger, Gerhard; Winearls, Christopher

2016-01-01

Background Extended dosing of the erythropoiesis-stimulating agent (ESA) darbepoetin alfa (DA) once biweekly or monthly reduces anaemia treatment burden. This observational study assessed outcomes and dosing patterns in patients with chronic kidney disease not on dialysis (CKD-NoD) commencing extended dosing of DA. Methods Adult CKD-NoD patients starting extended dosing of DA in Europe or Australia in June 2006 or later were followed up until December 2012. Outcomes included haemoglobin (Hb) concentration, ESA dosing, mortality rates and receipt of dialysis and renal transplantation. Subgroup analyses were conducted for selected outcomes. Results Of 6035 enrolled subjects, 5723 (94.8%) met analysis criteria; 1795 (29.7%) received dialysis and 238 (3.9%) underwent renal transplantation. Mean (standard deviation) Hb concentration at commencement of extended dosing was 11.0 (1.5) g/dL. Mean [95% confidence interval (CI)] Hb 12 months after commencement of extended dosing (primary outcome) was 11.6 g/dL (11.5, 11.6) overall and was similar across countries, with no differences between subjects previously treated with an ESA versus ESA-naïve subjects, subjects with versus without prior renal transplant or diabetics versus non-diabetics. Weekly ESA dose gradually decreased following commencement of extended DA dosing and was similar across subgroups. The decrease in weekly DA dose was accompanied by an increase in the proportion of patients receiving iron therapy. Hb concentrations declined following changes in ESA labels and treatment guidelines. The mortality rate (95% CI) was 7.06 (6.68, 7.46) deaths per 100 years of follow-up. Subjects alive at study end had stable Hb concentrations in the preceding year, while those who died had lower and declining Hb concentrations in their last year. Conclusions Long-term, extended dosing of DA maintained Hb concentrations in patients already treated with an ESA and corrected and maintained Hb in ESA-naïve patients. PMID

Conflict when making decisions about dialysis modality.

PubMed

Chen, Nien-Hsin; Lin, Yu-Ping; Liang, Shu-Yuan; Tung, Heng-Hsin; Tsay, Shiow-Luan; Wang, Tsae-Jyy

2018-01-01

To explore decisional conflict and its influencing factors on choosing dialysis modality in patients with end-stage renal diseases. The influencing factors investigated include demographics, predialysis education, dialysis knowledge, decision self-efficacy and social support. Making dialysis modality decisions can be challenging for patients with end-stage renal diseases; there are pros and cons to both haemodialysis and peritoneal dialysis. Patients are often uncertain as to which one will be the best alternative for them. This decisional conflict increases the likelihood of making a decision that is not based on the patient's values or preferences and may result in undesirable postdecisional consequences. Addressing factors predisposing patients to decisional conflict helps to facilitate informed decision-making and then to improve healthcare quality. A predictive correlational cross-sectional study design was used. Seventy patients were recruited from the outpatient dialysis clinics of two general hospitals in Taiwan. Data were collected with study questionnaires, including questions on demographics, dialysis modality and predialysis education, the Dialysis Knowledge Scale, the Decision Self-Efficacy scale, the Social Support Scale, and the Decisional Conflict Scale. The mean score on the Decisional Conflict Scale was 29.26 (SD = 22.18). Decision self-efficacy, dialysis modality, predialysis education, professional support and dialysis knowledge together explained 76.4% of the variance in decisional conflict. Individuals who had lower decision self-efficacy, did not receive predialysis education on both haemodialysis and peritoneal dialysis, had lower dialysis knowledge and perceived lower professional support reported higher decisional conflict on choosing dialysis modality. When providing decisional support to predialysis stage patients, practitioners need to increase patients' decision self-efficacy, provide both haemodialysis and peritoneal dialysis

Microcystin exposure and biochemical outcomes among dialysis patients

EPA Science Inventory

Background and aims Dialysis patients appear to be at special risk for exposure to cyanobacteria toxins; episodes of microcystin (MCYST) exposure via dialysate during 1996 and 2001 have been previously reported. During 2001, as many as 44 dialysis patients were exposed to contam...

Comparing mortality of peritoneal and hemodialysis patients in the first 2 years of dialysis therapy: a marginal structural model analysis.

PubMed

Lukowsky, Lilia R; Mehrotra, Rajnish; Kheifets, Leeka; Arah, Onyebuchi A; Nissenson, Allen R; Kalantar-Zadeh, Kamyar

2013-04-01

There are conflicting research results about the survival differences between hemodialysis and peritoneal dialysis, especially during the first 2 years of dialysis treatment. Given the challenges of conducting randomized trials, differential rates of modality switch and transplantation, and time-varying confounding in cohort data during the first years of dialysis treatment, use of novel analytical techniques in observational cohorts can help examine the peritoneal dialysis versus hemodialysis survival discrepancy. This study examined a cohort of incident dialysis patients who initiated dialysis in DaVita dialysis facilities between July of 2001 and June of 2004 and were followed for 24 months. This study used the causal modeling technique of marginal structural models to examine the survival differences between peritoneal dialysis and hemodialysis over the first 24 months, accounting for modality change, differential transplantation rates, and detailed time-varying laboratory measurements. On dialysis treatment day 90, there were 23,718 incident dialysis-22,360 hemodialysis and 1,358 peritoneal dialysis-patients. Incident peritoneal dialysis patients were younger, had fewer comorbidities, and were nine and three times more likely to switch dialysis modality and receive kidney transplantation over the 2-year period, respectively, compared with hemodialysis patients. In marginal structural models analyses, peritoneal dialysis was associated with persistently greater survival independent of the known confounders, including dialysis modality switch and transplant censorship (i.e., death hazard ratio of 0.52 [95% confidence limit 0.34-0.80]). Peritoneal dialysis seems to be associated with 48% lower mortality than hemodialysis over the first 2 years of dialysis therapy independent of modality switches or differential transplantation rates.

[Adequacy of dialysis at the Department of Nephrology and Dialysis of the Sveti Duh General Hospital in Zagreb and the Dialysis Outcomes Quality Initiative (DOQI) guidelines--comparison of the years 1998 and 2002].

PubMed

Janković, Nikola; Orsanić-Brcić, Dubravka; Pavlović, Drasko; Varlaj-Knobloch, Vesna; Altabas, Karmela

2003-01-01

Every year ever more and more patients in our country receive some form of dialysis, which provides life-saving renal replacement therapy for end-stage renal disease. In an effort to improve the quality and outcomes of dialysis care, the National Kidney Foundation--Dialysis Outcomes Quality Initiative (NKF-DOQI) have developed clinical practice guidelines for care of dialysis patients regarding hemodialysis adequacy, peritoneal dialysis adequacy, treatment of anemia, and vascular access. The morbidity and mortality of patients is strongly connected with dialysis adequacy and degree of anemia. We compared 180 patients on hemodialysis (HD) in 1998 and 177 patients in 2002, who are regularly treated in our Center with the use of DOQI guidelines. Dialysis adequacy was assessed by use of urea reduction ratio URR = 1-(post. urea/pre. urea), and overall wellbeing according to the degree of anemia, number of blood transfusions, presence of elevated blood pressure, and number of antihypertensives in therapy. In year 2002, 50% of the patients had adequate dialysis compared with 30% in 1998. The average duration on dialysis and the age of patients did not change. We recorded a rise in hemoglobin from 80 g/L to 92 g/L, and in the use of EPO (from 18% to 30%). No case of hypoalbuminemia was observed. The aim of dialysis is to improve the overall wellbeing of uremic patients. Comparing our results with DOQI-guidelines, we demonstrated that dialysis therapy could be improved to prevent complications and early mortality in dialysis patients.

Prevalence of Cognitive Impairment Among Peritoneal Dialysis Patients, Impact on Peritonitis and Role of Assisted Dialysis.

PubMed

Shea, Yat Fung; Lam, Man Fai; Lee, Mi Suen Connie; Mok, Ming Yee Maggie; Lui, Sing-Leung; Yip, Terence P S; Lo, Wai Kei; Chu, Leung Wing; Chan, Tak-Mao

2016-01-01

♦ Chronic renal failure and aging are suggested as risk factors for cognitive impairment (CI). We studied the prevalence of CI among peritoneal dialysis (PD) patients using Montreal Cognitive Assessment (MoCA), its impact on PD-related peritonitis in the first year, and the potential role of assisted PD. ♦ One hundred fourteen patients were newly started on PD between February 2011 and July 2013. Montreal Cognitive Assessment was performed in the absence of acute illness. Data on patient characteristics including demographics, comorbidities, blood parameters, dialysis adequacy, presence of helpers, medications, and the number PD-related infections were collected. ♦ The age of studied patients was 59±15.0 years, and 47% were female. The prevalence of CI was 28.9%. Patients older than 65 years old (odds ratio [OR] 4.88, confidence interval [CI] 1.79 - 13.28 p = 0.002) and with an education of primary level or below (OR 4.08, CI 1.30 - 12.81, p = 0.016) were independent risk factors for CI in multivariate analysis. Patients with PD-related peritonitis were significantly older (p < 0.001) and more likely to have CI as defined by MoCA (p = 0.035). After adjustment for age, however, CI was not a significant independent risk factor for PD-related peritonitis among self-care PD patients (OR 2.20, CI 0.65 - 7.44, p = 0.20). When we compared patients with MoCA-defined CI receiving self-care and assisted PD, there were no statistically significant differences between the 2 groups in terms of age, MoCA scores, or comorbidities. There were also no statistically significant differences in 1-year outcome of PD-related peritonitis rates or exit-site infections. ♦ Cognitive impairment is common among local PD patients. Even with CI, peritonitis rate in self-care PD with adequate training is similar to CI patients on assisted PD. Copyright © 2016 International Society for Peritoneal Dialysis.

Peritoneal Fluid Transport rather than Peritoneal Solute Transport Associates with Dialysis Vintage and Age of Peritoneal Dialysis Patients

PubMed Central

Waniewski, Jacek; Antosiewicz, Stefan; Baczynski, Daniel; Poleszczuk, Jan; Pietribiasi, Mauro; Lindholm, Bengt; Wankowicz, Zofia

2016-01-01

During peritoneal dialysis (PD), the peritoneal membrane undergoes ageing processes that affect its function. Here we analyzed associations of patient age and dialysis vintage with parameters of peritoneal transport of fluid and solutes, directly measured and estimated based on the pore model, for individual patients. Thirty-three patients (15 females; age 60 (21–87) years; median time on PD 19 (3–100) months) underwent sequential peritoneal equilibration test. Dialysis vintage and patient age did not correlate. Estimation of parameters of the two-pore model of peritoneal transport was performed. The estimated fluid transport parameters, including hydraulic permeability (LpS), fraction of ultrasmall pores (α u), osmotic conductance for glucose (OCG), and peritoneal absorption, were generally independent of solute transport parameters (diffusive mass transport parameters). Fluid transport parameters correlated whereas transport parameters for small solutes and proteins did not correlate with dialysis vintage and patient age. Although LpS and OCG were lower for older patients and those with long dialysis vintage, αu was higher. Thus, fluid transport parameters—rather than solute transport parameters—are linked to dialysis vintage and patient age and should therefore be included when monitoring processes linked to ageing of the peritoneal membrane. PMID:26989432

Effects of Physician Payment Reform on Provision of Home Dialysis

PubMed Central

Erickson, Kevin F.; Winkelmayer, Wolfgang C.; Chertow, Glenn M.; Bhattacharya, Jay

2016-01-01

Objectives Patients with end-stage renal disease can receive dialysis at home or in-center. In 2004 the Centers for Medicare and Medicaid Services reformed physician payment for in-center hemodialysis care from a capitated to a tiered fee-for-service model, augmenting physician payment for frequent in-center visits. We evaluated whether payment reform influenced dialysis modality assignment. Study Design Cohort study of patients starting dialysis in the US in the three years before and after payment reform. Methods We conducted difference-in-difference analyses comparing patients with Traditional Medicare coverage (who were affected by the policy) to others with Medicare Advantage (who were unaffected by the policy). We also examined whether the policy had a more pronounced influence on dialysis modality assignment in areas with lower costs of traveling to dialysis facilities. Results Patients with Traditional Medicare coverage experienced a 0.7% (95% CI 0.2%–1.1%; p=0.003) reduction in the absolute probability of home dialysis use following payment reform compared to patients with Medicare Advantage. Patients living in areas with larger dialysis facilities (where payment reform made in-center hemodialysis comparatively more lucrative for physicians) experienced a 0.9% (95% CI 0.5%–1.4%; p<0.001) reduction in home dialysis use following payment reform compared to patients living in areas with smaller facilities (where payment reform made in-center hemodialysis comparatively less lucrative for physicians). Conclusions Transition from a capitated to tiered fee-for-service payment model for dialysis care resulted in fewer patients receiving home dialysis. This area of policy failure highlights the importance of considering unintended consequences of future physician payment reform efforts. PMID:27355909

A Communication Framework for Dialysis Decision-Making for Frail Elderly Patients

PubMed Central

Cohen, Robert A.

2014-01-01

Frail elderly patients with advanced kidney disease experience many of the burdens associated with dialysis. Although these patients constitute the fastest-growing population starting dialysis, they often suffer loss of functional status, impaired quality of life, and increased mortality after dialysis initiation. Nephrology clinicians face the challenges of helping patients decide if the potential benefits of dialysis outweigh the risks and preparing such patients for future setbacks. A communication framework for dialysis decision-making that aligns treatment choices with patient goals and values is presented. The role of uncertainty is highlighted, and the concept of a goal-directed care plan is introduced. This plan incorporates a time-limited trial that promotes frequent opportunities for reassessment. Using the communication skills presented, the clinician can prepare and guide patients for the dialysis trajectory as it unfolds. PMID:24970868

The grown-up patient. The new customer in dialysis or--how to handle the demanding and emancipated dialysis patient.

PubMed

Hippold, I

2001-01-01

The treatment of dialysis patients is under pressure. As a result of strict budgeting and increased administrative work, enhancement and the further development of the dialysis health care system is needed. An essential element of that development is a radical change in the patient/nurse relationship. Customer relationship management assumes that the patient is seen as a client, is encouraged to make decisions on their treatment and also emphasises the professionalism of nursing.

Solute clearance measurement in the assessment of dialysis adequacy among African continuous ambulatory peritoneal dialysis patients.

PubMed

Abdu, Aliyu; Naidoo, Sagren; Malgas, Shirin; Naicker, Jocelyn T; Paget, Graham; Naicker, Saraladevi

2015-01-01

Solute clearance measurement is an objective means of quantifying the dose of peritoneal dialysis (PD). Despite continued debate on the interpretation and precise prognostic value of small solute clearance in PD patients, guidelines based on solute clearance values are common in clinical practice. There is limited information on the solute clearance indices and PD adequacy parameters among this predominantly low socioeconomic status PD population. We investigated the solute clearance among continuous ambulatory peritoneal dialysis (CAPD) patients at the Charlotte Maxeke Johannesburg Academic Hospital and its relationship with other parameters of PD adequacy. Seventy patients on CAPD were studied in this cross-sectional study. Solute clearance was assessed using urea clearance (Kt/V). Linear regression analysis was used to determine factors associated with solute clearance, while analysis of variance was used to test the influence of weekly Kt/V on blood pressure (BP), hemoglobin (Hb) and other biochemical parameters. The mean age of the study population was 37.9 ± 12.4 years, 43% were females and 86% were black Africans. The mean duration on CAPD was 19.7 ± 20.8 months. Mean systolic and diastolic BP were 144 ± 28 and 92 ± 17 mm Hg, respectively. The mean Hb was 11.1 ± 2.2 g/dL and the mean weekly Kt/V was 1.7 ± 0.3. Factors like systolic BP, Hb level, serum levels of cholesterol, calcium, phosphate, parathyroid hormone and albumin were not significantly associated with the weekly Kt/V. We conclude that the dose of PD received by the majority of our patients in terms of the weekly Kt/V is within the recommended values and that this finding is significant considering the low socioeconomic background of our patients. There is no significant association between Kt/V and other indices of dialysis adequacy.

Pharmacotherapy of Hypertension in Chronic Dialysis Patients

PubMed Central

Georgianos, Panagiotis I.

2016-01-01

Among patients on dialysis, hypertension is highly prevalent and contributes to the high burden of cardiovascular morbidity and mortality. Strict volume control via sodium restriction and probing of dry weight are first-line approaches for the treatment of hypertension in this population; however, antihypertensive drug therapy is often needed to control BP. Few trials compare head-to-head the superiority of one antihypertensive drug class over another with respect to improving BP control or altering cardiovascular outcomes; accordingly, selection of the appropriate antihypertensive regimen should be individualized. To individualize therapy, consideration should be given to intra- and interdialytic pharmacokinetics, effect on cardiovascular reflexes, ability to treat comorbid illnesses, and adverse effect profile. β-Blockers followed by dihydropyridine calcium-channel blockers are our first- and second-line choices for antihypertensive drug use. Angiotensin–converting enzyme inhibitors and angiotensin receptor blockers seem to be reasonable third–line choices, because the evidence base to support their use in patients on dialysis is sparse. Add-on therapy with mineralocorticoid receptor antagonists in specific subgroups of patients on dialysis (i.e., those with severe congestive heart failure) seems to be another promising option in anticipation of the ongoing trials evaluating their efficacy and safety. Adequately powered, multicenter, randomized trials evaluating hard cardiovascular end points are urgently warranted to elucidate the comparative effectiveness of antihypertensive drug classes in patients on dialysis. In this review, we provide an overview of the randomized evidence on pharmacotherapy of hypertension in patients on dialysis, and we conclude with suggestions for future research to address critical gaps in this important area. PMID:27797886

Historical Study (1986-2014): Improvements in Nutritional Status of Dialysis Patients.

PubMed

Koefoed, Mette; Kromann, Charles Boy; Hvidtfeldt, Danni; Juliussen, Sophie Ryberg; Andersen, Jens Rikardt; Marckmann, Peter

2016-09-01

Malnutrition is common in dialysis patients and is associated with adverse clinical outcomes. Despite an increased focus on improved nutrition in dialysis patients, it is claimed that the prevalence of malnutrition in this group of patients has not changed during the last decades. Direct historical comparisons of the nutritional status of dialysis patients have never been published. To directly compare the nutritional status of past and current dialysis patients, we implemented the methodology of a study from 1986 on a population of dialysis patients in 2014. Historical study comparing results of two cross-sectional studies performed in 1986 and 2014. We compared the nutritional status of hemodialysis (HD) and peritoneal dialysis (PD) patients attending the dialysis center at Roskilde Hospital, Denmark, in February to June 2014, with that of HD and PD patients treated at the dialysis center at Fredericia Hospital, Denmark, in April 1986. Maintenance PD and HD patients (n = 64 in 2014 and n = 48 in 1986). We performed anthropometry (body weight, triceps skinfold, and midarm muscle circumferences [MAMCs]) and determined plasma transferrin. Relative body weight, triceps skinfold, MAMC, body mass index, and prevalence of protein-caloric malnutrition as defined in the original study from 1986. Average relative body weight, triceps skinfold, MAMC, and body mass index were significantly higher in 2014 compared with 1986. The prevalence of protein-caloric malnutrition was significantly lower in 2014 (18%) compared with 1986 (52%). The nutritional status of maintenance dialysis patients has improved during the last 3 decades. The reason for this improvement could not be identified in the present study, but the most likely contributors are the higher prevalence of obesity in the general population, less predialytic malnutrition, and an improved focus on nutrition in maintenance dialysis patients. Copyright © 2016 National Kidney Foundation, Inc. Published by

Urgent-Start Peritoneal Dialysis and Hemodialysis in ESRD Patients: Complications and Outcomes.

PubMed

Jin, Haijiao; Fang, Wei; Zhu, Mingli; Yu, Zanzhe; Fang, Yan; Yan, Hao; Zhang, Minfang; Wang, Qin; Che, Xiajing; Xie, Yuanyuan; Huang, Jiaying; Hu, Chunhua; Zhang, Haifen; Mou, Shan; Ni, Zhaohui

2016-01-01

Several studies have suggested that urgent-start peritoneal dialysis (PD) is a feasible alternative to hemodialysis (HD) in patients with end-stage renal disease (ESRD), but the impact of the dialysis modality on outcome, especially on short-term complications, in urgent-start dialysis has not been directly evaluated. The aim of the current study was to compare the complications and outcomes of PD and HD in urgent-start dialysis ESRD patients. In this retrospective study, ESRD patients who initiated dialysis urgently without a pre-established functional vascular access or PD catheter at a single center from January 2013 to December 2014 were included. Patients were grouped according to their dialysis modality (PD and HD). Each patient was followed for at least 30 days after catheter insertion (until January 2016). Dialysis-related complications and patient survival were compared between the two groups. Our study enrolled 178 patients (56.2% male), of whom 96 and 82 patients were in the PD and HD groups, respectively. Compared with HD patients, PD patients had more cardiovascular disease, less heart failure, higher levels of serum potassium, hemoglobin, serum albumin, serum pre-albumin, and lower levels of brain natriuretic peptide. There were no significant differences in gender, age, use of steroids, early referral to a nephrologist, prevalence of primary renal diseases, prevalence of co-morbidities, and other laboratory characteristics between the groups. The incidence of dialysis-related complications during the first 30 days was significantly higher in HD than PD patients. HD patients had a significantly higher probability of bacteremia compared to PD patients. HD was an independent predictor of short-term (30-day) dialysis-related complications. There was no significant difference between PD and HD patients with respect to patient survival rate. In an experienced center, PD is a safe and feasible dialysis alternative to HD for ESRD patients with an urgent need

Oral health status of dialysis patients based on their renal dialysis history in Kerman, Iran.

PubMed

Chamani, Goli; Zarei, Mohammad Reza; Radvar, Mehrdad; Rashidfarrokhi, Farin; Razazpour, Fateme

2009-01-01

Maintaining a high level of periodontal and oral health in patients undergoing renal dialysis is of paramount importance because of the inherent compromised host defence mechanisms. The aim of the present study was to determine the periodontal status and the level of dental caries in renal dialysis patients in Kerman, Iran. A cross-sectional study was conducted on two groups of patients: one including 68 renal dialysis patients (test) and the other including 30 healthy subjects (control). Half-mouth measurements of Gingival Index (GI), Plaque Index (PI), probing pocket depth (PPD), gingival recession (GR), clinical attachment level (CAL) and bleeding on probing (BOP) as well as decayed, missing or filled teeth (DMFT) index were recorded. The GI, BOP, PPD, CAL and GR were significantly greater among the test group as compared with the control group; however, the DMFT did not differ significantly among the groups. There was no relationship between the duration of the dialysis and the periodontal indices. It seems that patients with chronic renal failure have less favourable periodontal health than normal patients. The present study showed that oral home care practices were inadequate. Thus, preventive programmes to promote the oral health status of haemodialysis patients are needed.

Glycemic Control and Mortality in Diabetic Patients Undergoing Dialysis Focusing on the Effects of Age and Dialysis Type: A Prospective Cohort Study in Korea.

PubMed

Park, Ji In; Bae, Eunjin; Kim, Yong-Lim; Kang, Shin-Wook; Yang, Chul Woo; Kim, Nam-Ho; Lee, Jung Pyo; Kim, Dong Ki; Joo, Kwon Wook; Kim, Yon Su; Lee, Hajeong

2015-01-01

Active glycemic control has been proven to delay the onset and slow the progression of diabetic retinopathy, nephropathy, and neuropathy in diabetic patients, but the optimal level is obscure in end-stage renal disease. In this study, we evaluated the effect of hemoglobin A1c (HbA1c) on mortality of diabetic patients on dialysis, focusing on age and dialysis type. Of 3,302 patients enrolled in the prospective cohort for end-stage renal disease in Korea between August 2008 and October 2013, 1,239 diabetic patients who had been diagnosed with diabetes or having HbA1c≥6.5% at the time of enrollment were analyzed. Age was categorized as <55, 55-64 and ≥65 years old. Age, sex, modified Charlson comorbidity index, hemoglobin, primary renal disease, body mass index, and dialysis duration were adjusted. A total of 873 patients received hemodialysis (HD) and 366 underwent peritoneal dialysis (PD). During the mean follow-up of 19.1 months, 141 patients died. Patients with poor glucose control (HbA1c≥8%) showed worse survival than patients with HbA1c<8% (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.48-3.29; P<0.001). Subgroup analysis divided by age revealed that HbA1c≥8% was a predictor of mortality in age <55 (HR, 4.3; 95% CI, 1.78-10.41; P = 0.001) and age 55-64 groups (HR, 3.3; 95% CI, 1.56-7.05; P = 0.002), but not in age ≥65 group. Combining dialysis type and age, poor glucose control negatively affected survival only in age < 55 group among HD patients, but it was significant in age < 55 and age 55-64 groups in PD patients. Deaths from infection were more prevalent in the PD group, and poor glucose control tended to correlate with more deaths from infection in PD patients (P = 0.050). In this study, the effect of glycemic control differed according to age and dialysis type in diabetic patients. Thus, the target of glycemic control should be customized; further observational studies may strengthen the clinical relevance.

Magnitude of discordance between registry data and death certificate when evaluating leading causes of death in dialysis patients.

PubMed

Lafrance, Jean-Philippe; Rahme, Elham; Iqbal, Sameena; Leblanc, Martine; Pichette, Vincent; Elftouh, Naoual; Vallée, Michel

2013-03-27

Discordance between dialysis registry and death certificate reported death has been demonstrated. Since cause of death is measured using registry data in dialysis patients and death certificate data in the general population, comparisons of cause of death proportions between dialysis patients and the general population may be biased. Our aim was to compare the proportion of deaths attributed to cardiovascular disease (CVD), malignancy, and infections between patients receiving dialysis and the general population using death certificates for both, and to quantify the magnitude of discrepancy between registry and death certificate estimates in dialysis patients. A retrospective cohort study of 5858 patients initiating maintenance dialysis between 2001 and 2007 was conducted. Cause of death was obtained from both registry and death certificate data for dialysis patients, and from death certificate data for the general population. Compared to the general population, use of death certificate data in dialysis patients resulted in smaller differences in the proportion of deaths attributed to CVD or infection than that from the registry. In the general population, the proportion of deaths due to CVD is 29.3% for men and 28.2% for women, and the proportion of deaths due to infection is 3.3% for men and 3.6% for women. For men, the proportion of deaths in dialysis patients due to CVD using registry data is 41.5%, compared with a proportion of 32.1% using death certificate data. Similarly for women, the proportion of deaths due to CVD using registry data is 35.2% and that using death certificate data 24.3%. The proportion of deaths due to infection in dialysis patients follows the same pattern: for men, the proportion of deaths due to infection using registry data is 9.9% and that from death certificate data at 5.0%; while for women the proportions are 11.6% and 4.8%, respectively. While absolute cause-specific mortality rates did differ, evaluation of causes of death using

Influenza and pneumococcal vaccinations in dialysis patients in a London district general hospital.

PubMed

Wilmore, Stephanie M S; Philip, Keir E; Cambiano, Valentina; Bretherton, Christopher P; Harborne, Josephine E; Sharma, Aditi; Jayasena, Shyama D

2014-02-01

Patients on dialysis mount reduced immune responses compared with the general population. The Department of Health advises that these patients receive influenza and pneumococcal vaccinations at regular intervals-once yearly and every five years, respectively. This article investigates the uptake of these vaccinations in this patient population and seeks to examine factors that may influence vaccination status such as patient's language and presence of a general practitioner (GP) electronic vaccination reminder system. It also explores preferred site of vaccination for patients and GPs as these are primary care vaccinations yet patients have more frequent contact with their dialysis unit than their GP, blurring the boundaries between primary and specialized care. This is a retrospective study of all patients registered as dialysing at the North Middlesex University Hospital NHS Trust (NMUH) in September 2011. Information was obtained through GP letters, GP and patient questionnaires. Of 154 patients, 133 were included in the data analysis. Nineteen per cent were up-to-date with both vaccinations and 67% with their influenza vaccination. Fifty per cent had received the influenza vaccination in the last two consecutive years. Thirty per cent were not up-to-date with either vaccination. There was no evidence of a difference in uptake in 2009 (P = 0.7564) and in 2010 (P = 0.7435) among those who could and could not speak English. Twenty-five per cent of GPs and 58.6% of patients preferred vaccination to occur in the dialysis unit. Unfortunately a high number of GPs did not provide information on whether they used an electronic vaccination reminder but the analysis from the information provided by the few respondents did not reveal any correlation between the presence of an electronic reminder and vaccination status. Most dialysis patients were not up-to-date with both vaccinations. They were, however, more up-to-date with their influenza than their pneumococcal

Influenza and pneumococcal vaccinations in dialysis patients in a London district general hospital

PubMed Central

Wilmore, Stephanie M.S.; Philip, Keir E.; Cambiano, Valentina; Bretherton, Christopher P.; Harborne, Josephine E.; Sharma, Aditi; Jayasena, Shyama D.

2014-01-01

Background Patients on dialysis mount reduced immune responses compared with the general population. The Department of Health advises that these patients receive influenza and pneumococcal vaccinations at regular intervals—once yearly and every five years, respectively. This article investigates the uptake of these vaccinations in this patient population and seeks to examine factors that may influence vaccination status such as patient's language and presence of a general practitioner (GP) electronic vaccination reminder system. It also explores preferred site of vaccination for patients and GPs as these are primary care vaccinations yet patients have more frequent contact with their dialysis unit than their GP, blurring the boundaries between primary and specialized care. Methods This is a retrospective study of all patients registered as dialysing at the North Middlesex University Hospital NHS Trust (NMUH) in September 2011. Information was obtained through GP letters, GP and patient questionnaires. Results Of 154 patients, 133 were included in the data analysis. Nineteen per cent were up-to-date with both vaccinations and 67% with their influenza vaccination. Fifty per cent had received the influenza vaccination in the last two consecutive years. Thirty per cent were not up-to-date with either vaccination. There was no evidence of a difference in uptake in 2009 (P = 0.7564) and in 2010 (P = 0.7435) among those who could and could not speak English. Twenty-five per cent of GPs and 58.6% of patients preferred vaccination to occur in the dialysis unit. Unfortunately a high number of GPs did not provide information on whether they used an electronic vaccination reminder but the analysis from the information provided by the few respondents did not reveal any correlation between the presence of an electronic reminder and vaccination status. Conclusion Most dialysis patients were not up-to-date with both vaccinations. They were, however, more up-to-date with their

Effects of physician payment reform on provision of home dialysis.

PubMed

Erickson, Kevin F; Winkelmayer, Wolfgang C; Chertow, Glenn M; Bhattacharya, Jay

2016-06-01

Patients with end-stage renal disease can receive dialysis at home or in-center. In 2004, CMS reformed physician payment for in-center hemodialysis care from a capitated to a tiered fee-for-service model, augmenting physician payment for frequent in-center visits. We evaluated whether payment reform influenced dialysis modality assignment. Cohort study of patients starting dialysis in the United States in the 3 years before and the 3 years after payment reform. We conducted difference-in-difference analyses comparing patients with traditional Medicare coverage (who were affected by the policy) to others with Medicare Advantage (who were unaffected by the policy). We also examined whether the policy had a more pronounced influence on dialysis modality assignment in areas with lower costs of traveling to dialysis facilities. Patients with traditional Medicare coverage experienced a 0.7% (95% CI, 0.2%-1.1%; P = .003) reduction in the absolute probability of home dialysis use following payment reform compared with patients with Medicare Advantage. Patients living in areas with larger dialysis facilities (where payment reform made in-center hemodialysis comparatively more lucrative for physicians) experienced a 0.9% (95% CI, 0.5%-1.4%; P < .001) reduction in home dialysis use following payment reform compared with patients living in areas with smaller facilities (where payment reform made in-center hemodialysis comparatively less lucrative for physicians). The transition from a capitated to a tiered fee-for-service payment model for in-center hemodialysis care resulted in fewer patients receiving home dialysis. This area of policy failure highlights the importance of considering unintended consequences of future physician payment reform efforts.

Glycemic Control Modifies Difference in Mortality Risk Between Hemodialysis and Peritoneal Dialysis in Incident Dialysis Patients With Diabetes

PubMed Central

Lee, Mi Jung; Kwon, Young Eun; Park, Kyoung Sook; Kee, Youn Kyung; Yoon, Chang-Yun; Han, In Mee; Han, Seung Gyu; Oh, Hyung Jung; Park, Jung Tak; Han, Seung Hyeok; Yoo, Tae-Hyun; Kim, Yong-Lim; Kim, Yon Su; Yang, Chul Woo; Kim, Nam-Ho; Kang, Shin-Wook

2016-01-01

Abstract Although numerous studies have tried to elucidate the best dialysis modality in end-stage renal disease patients with diabetes, results were inconsistent and varied with the baseline characteristics of patients. Furthermore, none of the previous studies on diabetic dialysis patients accounted for the impact of glycemic control. We explored whether glycemic control had modifying effect on mortality between hemodialysis (HD) and peritoneal dialysis (PD) in incident dialysis patients with diabetes. A total of 902 diabetic patients who started dialysis between August 2008 and December 2013 were included from a nationwide prospective cohort in Korea. Based on the interaction analysis between hemoglobin A1c (HbA1c) and dialysis modalities for patient survival (P for interaction = 0.004), subjects were stratified into good and poor glycemic control groups (HbA1c< or ≥8.0%). Differences in survival rates according to dialysis modalities were ascertained in each glycemic control group after propensity score matching. During a median follow-up duration of 28 months, the relative risk of death was significantly lower in PD compared with HD in the whole cohort and unmatched patients (whole cohort, hazard ratio [HR] = 0.65, 95% confidence interval [CI] = 0.47–0.90, P = 0.01; patients with available HbA1c [n = 773], HR = 0.64, 95% CI = 0.46–0.91, P = 0.01). In the good glycemic control group, there was a significant survival advantage of PD (HbA1c <8.0%, HR = 0.59, 95% CI = 0.37–0.94, P = 0.03). However, there was no significant difference in survival rates between PD and HD in the poor glycemic control group (HbA1c ≥8.0%, HR = 1.21, 95% CI = 0.46–2.76, P = 0.80). This study demonstrated that the degree of glycemic control modified the mortality risk between dialysis modalities, suggesting that glycemic control might partly contribute to better survival of PD in incident dialysis patients with diabetes

Predicting Early Death Among Elderly Dialysis Patients: Development and Validation of a Risk Score to Assist Shared Decision Making for Dialysis Initiation.

PubMed

Thamer, Mae; Kaufman, James S; Zhang, Yi; Zhang, Qian; Cotter, Dennis J; Bang, Heejung

2015-12-01

A shared decision-making tool could help elderly patients with advanced chronic kidney disease decide about initiating dialysis therapy. Because mortality may be high in the first few months after initiating dialysis therapy, incorporating early mortality predictors in such a tool would be important for an informed decision. Our objective is to derive and validate a predictive risk score for early mortality after initiating dialysis therapy. Retrospective observational cohort, with development and validation cohorts. US Renal Data System and claims data from the Centers for Medicare & Medicaid Services for 69,441 (aged ≥67 years) patients with end-stage renal disease with a previous 2-year Medicare history who initiated dialysis therapy from January 1, 2009, to December 31, 2010. Demographics, predialysis care, laboratory data, functional limitations, and medical history. All-cause mortality in the first 3 and 6 months. Predicted mortality by logistic regression. The simple risk score (total score, 0-9) included age (0-3 points), low albumin level, assistance with daily living, nursing home residence, cancer, heart failure, and hospitalization (1 point each), and showed area under the receiver operating characteristic curve (AUROC)=0.69 in the validation sample. A comprehensive risk score with additional predictors was also developed (with AUROC=0.72, high concordance between predicted vs observed risk). Mortality probabilities were estimated from these models, with the median score of 3 indicating 12% risk in 3 months and 20% in 6 months, and the highest scores (≥8) indicating 39% risk in 3 months and 55% in 6 months. Patients who did not choose dialysis therapy and did not have a 2-year Medicare history were excluded. Routinely available information can be used by patients with chronic kidney disease, families, and their nephrologists to estimate the risk of early mortality after dialysis therapy initiation, which may facilitate informed decision making

Complications and Mortality in Chronic Renal Failure Patients Undergoing Total Joint Arthroplasty: A Comparison Between Dialysis and Renal Transplant Patients.

PubMed

Cavanaugh, Priscilla K; Chen, Antonia F; Rasouli, Mohammad R; Post, Zachary D; Orozco, Fabio R; Ong, Alvin C

2016-02-01

In total joint arthroplasty (TJA) literature, there is a paucity of large cohort studies comparing chronic kidney disease (CKD) and end-stage renal disease (ESRD) vs non-CKD/ESRD patients. Thus, the purposes of this study were (1) to identify inhospital complications and mortality in CKD/ESRD and non-CKD/ESRD patients and (2) compare inhospital complications and mortality between dialysis and renal transplantation patients undergoing TJA. We queried the Nationwide Inpatient Sample database for patients with and without diagnosis of CKD/ESRD and those with a renal transplant or on dialysis undergoing primary or revision total knee or hip arthroplasty from 2007 to 2011. Patient comorbidities were identified using the Elixhauser comorbidity index. International Classification of Diseases, Ninth Revision, codes were used to identify postoperative surgical site infections (SSIs), wound complications, deep vein thrombosis, and transfusions. Chronic kidney disease/ESRD was associated with greater risk of SSIs (odds ratio [OR], 1.4; P<.001), wound complications (OR, 1.1; P=.01), transfusions (OR, 1.6; P<.001), deep vein thrombosis (OR, 1.4; P=.03), and mortality (OR, 2.1; P<.001) than non-CKD/ESRD patients. Dialysis patients had higher rates of SSI, wound complications, transfusions, and mortality compared to renal transplant patients. Chronic kidney disease/ESRD patients had a greater risk of SSIs and wound complications compared to those without renal disease, and the risk of these complications was even greater in CKD/ESRD patients receiving dialysis. These findings emphasize the importance of counseling CKD patients about higher potential complications after TJA, and dialysis patients may be encouraged to undergo renal transplantation before TJA. Copyright © 2016 Elsevier Inc. All rights reserved.

Cardiac surgery in patients with end-stage renal disease on dialysis.

PubMed

Bäck, Caroline; Hornum, Mads; Møller, Christian Joost Holdflod; Olsen, Peter Skov

2017-12-01

Over the past decade, the number of patients on dialysis and with cardiovascular diseases has steadily increased. This retrospective analysis compares the postoperative mortality after cardiac surgery between patients on hemodialysis and peritoneal dialysis. Between 1998 and 2015, 136 patients with end-stage renal disease initiating dialysis more than one month before surgery underwent cardiac surgery. Demographics, preoperative hemodynamic and biochemical data were collected from the patient records. Vital status and date of death was retrieved from a national register. Hemodialysis was undertaken in 73% and peritoneal dialysis in 22% of patients aged 59.7 ± 12.9 years, mean EuroSCORE 8.6% ± 3.5. Isolated coronary artery bypass graft was performed in 46%, isolated valve procedure in 29% and combined procedures in 24% with no significant statistical difference between groups. The 30-day mortality was 14% for hemodialysis patients and 3% for peritoneal dialysis patients (p = .056). One-year and 5-year mortality were, 30% and 59% in the hemodialysis group, 30% and 57% in the peritoneal dialysis group (p = .975, p = .852). Independent predictors of total mortality were age (p = .001), diabetes (p = .017) and active endocarditis (p = .012). No statistically significant difference in mortality was found between patients in hemo- or peritoneal dialysis. However, we observed that patients with end-stage renal disease on dialysis have two times higher mortality rate than estimated by EuroSCORE.

Caring for Older Patients on Peritoneal Dialysis at End of Life.

PubMed

Meeus, Frédérique; Brown, Edwina A

2015-11-01

End of life is the last phase of life, not merely the last few days. For many older patients on peritoneal dialysis (PD), the end-of-life phase commences with the start of dialysis. The principal aim of management of this phase should be optimizing the quality of life of the patient. Evidence suggests that patients on dialysis mostly want involvement in decisions at this stage, but most do not have the opportunity to do so. Management should therefore include discussions with the patient and their family to determine lifestyle goals, treatment wishes, and ceilings of care (including resuscitation and dialysis withdrawal). Care should also include symptom identification and management, psychosocial support, and adaptation of dialysis to the ability and needs of the patient. By doing this, quality of life at end of life is achievable. Copyright © 2015 International Society for Peritoneal Dialysis.

Standardized Prevalence Ratios for Atrial Fibrillation in Adult Dialysis Patients in Japan.

PubMed

Ohsawa, Masaki; Tanno, Kozo; Okamura, Tomonori; Yonekura, Yuki; Kato, Karen; Fujishima, Yosuke; Obara, Wataru; Abe, Takaya; Itai, Kazuyoshi; Ogasawara, Kuniaki; Omama, Shinichi; Turin, Tanvir Chowdhury; Miyamatsu, Naomi; Ishibashi, Yasuhiro; Morino, Yoshihiro; Itoh, Tomonori; Onoda, Toshiyuki; Kuribayashi, Toru; Makita, Shinji; Yoshida, Yuki; Nakamura, Motoyuki; Tanaka, Fumitaka; Ohta, Mutsuko; Sakata, Kiyomi; Okayama, Akira

2016-05-05

While it is assumed that dialysis patients in Japan have a higher prevalence of atrial fibrillation (AF) than the general population, the magnitude of this difference is not known. Standardized prevalence ratios (SPRs) for AF in dialysis patients (n = 1510) were calculated compared to data from the general population (n = 26 454) living in the same area. The prevalences of AF were 3.8% and 1.6% in dialysis patients and the general population, respectively. In male subjects, these respective values were 4.9% and 3.3%, and in female subjects they were 1.6% and 0.6%. The SPRs for AF were 2.53 (95% confidence interval [CI], 1.88-3.19) in all dialysis patients, 1.80 (95% CI, 1.30-2.29) in male dialysis patients, and 2.13 (95% CI, 0.66-3.61) in female dialysis patients. The prevalence of AF in dialysis patients was twice that in the population-based controls. Since AF strongly contributes to a higher risk of cardiovascular mortality and morbidity in the general population, further longitudinal studies should be conducted regarding the risk of several outcomes attributable to AF among Japanese dialysis patients.

Ambulatory Medication Reconciliation in Dialysis Patients: Benefits and Community Practitioners’ Perspectives

PubMed Central

Wilson, Jo-Anne S; Ladda, Matthew A; Tran, Jaclyn; Wood, Marsha; Poyah, Penelope; Soroka, Steven; Rodrigues, Glenn; Tennankore, Karthik

2017-01-01

Background Ambulatory medication reconciliation can reduce the frequency of medication discrepancies and may also reduce adverse drug events. Patients receiving dialysis are at high risk for medication discrepancies because they typically have multiple comorbid conditions, are taking many medications, and are receiving care from many practitioners. Little is known about the potential benefits of ambulatory medication reconciliation for these patients. Objectives To determine the number, type, and potential level of harm associated with medication discrepancies identified through ambulatory medication reconciliation and to ascertain the views of community pharmacists and family physicians about this service. Methods This retrospective cohort study involved patients initiating hemodialysis who received ambulatory medication reconciliation in a hospital renal program over the period July 2014 to July 2016. Discrepancies identified on the medication reconciliation forms for study patients were extracted and categorized by discrepancy type and potential level of harm. The level of harm was determined independently by a pharmacist and a nurse practitioner using a defined scoring system. In the event of disagreement, a nephrologist determined the final score. Surveys were sent to 52 community pharmacists and 44 family physicians involved in the care of study patients to collect their opinions and perspectives on ambulatory medication reconciliation. Results Ambulatory medication reconciliation was conducted 296 times for a total of 147 hemodialysis patients. The mean number of discrepancies identified per patient was 1.31 (standard deviation 2.00). Overall, 30% of these discrepancies were deemed to have the potential to cause moderate to severe patient discomfort or clinical deterioration. Survey results indicated that community practitioners found ambulatory medication reconciliation valuable for providing quality care to dialysis patients. Conclusions This study has

Comparing Mortality of Peritoneal and Hemodialysis Patients in the First 2 Years of Dialysis Therapy: A Marginal Structural Model Analysis

PubMed Central

Lukowsky, Lilia R.; Mehrotra, Rajnish; Kheifets, Leeka; Arah, Onyebuchi A.; Nissenson, Allen R.

2013-01-01

Summary Background and objectives There are conflicting research results about the survival differences between hemodialysis and peritoneal dialysis, especially during the first 2 years of dialysis treatment. Given the challenges of conducting randomized trials, differential rates of modality switch and transplantation, and time-varying confounding in cohort data during the first years of dialysis treatment, use of novel analytical techniques in observational cohorts can help examine the peritoneal dialysis versus hemodialysis survival discrepancy. Design, setting, participants, & measurements This study examined a cohort of incident dialysis patients who initiated dialysis in DaVita dialysis facilities between July of 2001 and June of 2004 and were followed for 24 months. This study used the causal modeling technique of marginal structural models to examine the survival differences between peritoneal dialysis and hemodialysis over the first 24 months, accounting for modality change, differential transplantation rates, and detailed time-varying laboratory measurements. Results On dialysis treatment day 90, there were 23,718 incident dialysis—22,360 hemodialysis and 1,358 peritoneal dialysis—patients. Incident peritoneal dialysis patients were younger, had fewer comorbidities, and were nine and three times more likely to switch dialysis modality and receive kidney transplantation over the 2-year period, respectively, compared with hemodialysis patients. In marginal structural models analyses, peritoneal dialysis was associated with persistently greater survival independent of the known confounders, including dialysis modality switch and transplant censorship (i.e., death hazard ratio of 0.52 [95% confidence limit 0.34–0.80]). Conclusions Peritoneal dialysis seems to be associated with 48% lower mortality than hemodialysis over the first 2 years of dialysis therapy independent of modality switches or differential transplantation rates. PMID:23307879

Secular trends in acute dialysis after elective major surgery — 1995 to 2009

PubMed Central

Siddiqui, Nausheen F.; Coca, Steven G.; Devereaux, Philip J.; Jain, Arsh K.; Li, Lihua; Luo, Jin; Parikh, Chirag R.; Paterson, Michael; Philbrook, Heather Thiessen; Wald, Ron; Walsh, Michael; Whitlock, Richard; Garg, Amit X.

2012-01-01

Background: Acute kidney injury is a serious complication of elective major surgery. Acute dialysis is used to support life in the most severe cases. We examined whether rates and outcomes of acute dialysis after elective major surgery have changed over time. Methods: We used data from Ontario’s universal health care databases to study all consecutive patients who had elective major surgery at 118 hospitals between 1995 and 2009. Our primary outcomes were acute dialysis within 14 days of surgery, death within 90 days of surgery and chronic dialysis for patients who did not recover kidney function. Results: A total of 552 672 patients underwent elective major surgery during the study period, 2231 of whom received acute dialysis. The incidence of acute dialysis increased steadily from 0.2% in 1995 (95% confidence interval [CI] 0.15–0.2) to 0.6% in 2009 (95% CI 0.6–0.7). This increase was primarily in cardiac and vascular surgeries. Among patients who received acute dialysis, 937 died within 90 days of surgery (42.0%, 95% CI 40.0–44.1), with no change in 90-day survival over time. Among the 1294 patients who received acute dialysis and survived beyond 90 days, 352 required chronic dialysis (27.2%, 95% CI 24.8–29.7), with no change over time. Interpretation: The use of acute dialysis after cardiac and vascular surgery has increased substantially since 1995. Studies focusing on interventions to better prevent and treat perioperative acute kidney injury are needed. PMID:22733671

Social functioning and socioeconomic changes after introduction of regular dialysis treatment and impact of dialysis modality: a multi-centre survey of Japanese patients.

PubMed

Nakayama, Masaaki; Ishida, Mari; Ogihara, Masahiko; Hanaoka, Kazushige; Tamura, Masahito; Kanai, Hidetoshi; Tonozuka, Yukio; Marshall, Mark R

2015-08-01

Patient socialization and preservation of socioeconomic status are important patient-centred outcomes for those who start dialysis, and retention of employment is a key enabler. This study examined the influence of dialysis inception and modality upon these outcomes in a contemporary Japanese cohort. We conducted a survey of prevalent chronic dialysis patients from 5 dialysis centres in Japan. All patients who had been on peritoneal dialysis (PD) since dialysis inception were recruited, and matched with a sample of those on in-centre haemodialysis (ICHD). We assessed patients' current social functioning (Short Form 36 Health Survey), and evaluated changes to patient employment status, annual income, and general health condition from the pre-dialysis period to the current time. A total of 179 patients were studied (102 PD and 77 ICHD). There were no differences in social functioning by modality. Among them, 113 were employed in the pre-dialysis period with no difference by modality. Of these, 22% became unemployed after dialysis inception, with a corresponding decline in average working hours and annual income. The odds of unemployment after dialysis inception were 5.02 fold higher in those on ICHD compared to those on PD, after adjustment for covariates. There were no changes for those who were already unemployed in the pre-dialysis period. Employment status is significantly hampered by dialysis inception, although PD was associated with superior retention of employment and greater income compared to ICHD. This supports a positive role for PD in preservation of socioeconomic status and potentially other patient-centred outcomes. © 2015 Asian Pacific Society of Nephrology.

Opioid Prescription, Morbidity, and Mortality in United States Dialysis Patients.

PubMed

Kimmel, Paul L; Fwu, Chyng-Wen; Abbott, Kevin C; Eggers, Anne W; Kline, Prudence P; Eggers, Paul W

2017-12-01

Aggressive pain treatment was advocated for ESRD patients, but new Centers for Disease Control and Prevention guidelines recommend cautious opioid prescription. Little is known regarding outcomes associated with ESRD opioid prescription. We assessed opioid prescriptions and associations between opioid prescription and dose and patient outcomes using 2006-2010 US Renal Data System information in patients on maintenance dialysis with Medicare Part A, B, and D coverage in each study year ( n =671,281, of whom 271,285 were unique patients). Opioid prescription was confirmed from Part D prescription claims. In the 2010 prevalent cohort ( n =153,758), we examined associations of opioid prescription with subsequent all-cause death, dialysis discontinuation, and hospitalization controlled for demographics, comorbidity, modality, and residence. Overall, >60% of dialysis patients had at least one opioid prescription every year. Approximately 20% of patients had a chronic (≥90-day supply) opioid prescription each year, in 2010 usually for hydrocodone, oxycodone, or tramadol. In the 2010 cohort, compared with patients without an opioid prescription, patients with short-term (1-89 days) and chronic opioid prescriptions had increased mortality, dialysis discontinuation, and hospitalization. All opioid drugs associated with mortality; most associated with worsened morbidity. Higher opioid doses correlated with death in a monotonically increasing fashion. We conclude that opioid drug prescription is associated with increased risk of death, dialysis discontinuation, and hospitalization in dialysis patients. Causal relationships cannot be inferred, and opioid prescription may be an illness marker. Efforts to treat pain effectively in patients on dialysis yet decrease opioid prescriptions and dose deserve consideration. Copyright © 2017 by the American Society of Nephrology.

Quality of life in patients on chronic dialysis in South Africa: a comparative mixed methods study.

PubMed

Tannor, Elliot K; Archer, Elize; Kapembwa, Kenneth; van Schalkwyk, Susan C; Davids, M Razeen

2017-01-05

The increasing prevalence of treated end-stage renal disease and low transplant rates in Africa leads to longer durations on dialysis. Dialysis should not only be aimed at prolonging lives but also improve quality of life (QOL). Using mixed methods, we investigated the QOL of patients on chronic haemodialysis (HD) and peritoneal dialysis (PD). We conducted a cross-sectional study at Tygerberg Hospital in Cape Town, South Africa. All the PD patients were being treated with continuous ambulatory peritoneal dialysis. The KDQOL-SF 1.3 questionnaire was used for the quantitative phase of the study. Thereafter, focus-group interviews were conducted by an experienced facilitator in groups of HD and PD patients. Electronic recordings were transcribed verbatim and analysed manually to identify emerging themes. A total of 106 patients completed questionnaires and 36 of them participated in the focus group interviews. There was no difference between PD and HD patients in the overall KDQOL-SF scores. PD patients scored lower with regard to symptoms (P = 0.005), energy/fatigue (P = 0.025) and sleep (P = 0.023) but scored higher for work status (P = 0.005) and dialysis staff encouragement (P = 0.019) than those on HD. Symptoms and complications were verbalised more in the PD patients, with fear of peritonitis keeping some housebound. PD patients were more limited by their treatment modality which impacted on body image, sexual function and social interaction but there were less dietary and occupational limitations. Patients on each modality acknowledged the support received from family and dialysis staff but highlighted the lack of support from government. PD patients had little opportunity for interaction with one another and therefore enjoyed less support from fellow patients. PD patients experienced a heavier symptom burden and greater limitations related to their dialysis modality, especially with regards to social functioning. The mixed-methods approach

Long-term outcome on renal replacement therapy in patients who previously received a keto acid-supplemented very-low-protein diet.

PubMed

Chauveau, Philippe; Couzi, Lionel; Vendrely, Benoit; de Précigout, Valérie; Combe, Christian; Fouque, Denis; Aparicio, Michel

2009-10-01

The consequences of a supplemented very-low-protein diet remain a matter of debate with regard to patient outcome before or after the onset of renal replacement therapy. We evaluated the long-term clinical outcome during maintenance dialysis and/or transplantation in patients who previously received a supplemented very-low-protein diet. We assessed the outcome of 203 patients who received a supplemented very-low-protein diet for >3 mo (inclusion period: 1985-2000) and started dialysis after a mean diet duration of 33.1 mo (4-230 mo). The survival rate in the whole cohort was 79% and 63% at 5 and 10 y, respectively. One hundred two patients continued with chronic dialysis during the entire follow-up, and 101 patients were grafted at least once. Patient outcomes were similar to those of the French Dialysis Registry patients for the dialysis group and similar to the 865 patients who were transplanted in Bordeaux during the same period for the transplant group. There was no correlation between death rate and duration of diet. The lack of correlation between death rate and duration of diet and the moderate mortality rate observed during the first 10 y of renal replacement therapy confirm that a supplemented very-low-protein diet has no detrimental effect on the outcome of patients with chronic kidney disease who receive renal replacement therapy.

Does a patent foramen ovale influence cognitive function in dialysis patients?

PubMed

George, Sudhakar; Holt, Stephen; Medford, Nick; Hildick-Smith, David

2013-01-01

Patients with chronic kidney disease on dialysis treatment have poorer cognitive function than age- and sex-matched controls. One proposed mechanism is cerebral microembolisation due to material from the dialysis circuit crossing a patent foramen ovale (PFO). Cognitive testing was carried out in haemodialysis (HD) patients and peritoneal dialysis (PD) patients. Transthoracic echocardiography was used to identify PFO. Follow-up testing 1 year later enabled comparison of cognitive decline between patients with and without a PFO, and between those undergoing different dialysis modalities. 80 patients (aged 60.4 ± 15.0 years) were recruited (51 HD patients and 29 PD controls). A PFO was found in 21% of patients. 83% of dialysis patients suffered a decline in one or more cognitive function tests over 1 year. There was a significant difference in only one test between HD patients with or without a PFO. PD patients showed a more rapid cognitive decline than those on HD. Cognitive decline in dialysis patients is rapid and affects most patients. The presence of a PFO made only subtle differences to the rates of cognitive decline during 1 year of follow-up. Patients with a PFO should not be prevented from considering HD because of concerns of cerebral decline due to microembolisation. Copyright © 2013 S. Karger AG, Basel.

Managing peritoneal dialysis (PD)--factors that influence patients' modification of their recommended dialysis regimen. A European study of 376 patients.

PubMed

Hollis, Jane; Harman, Wendy; Goovearts, T; Paris, V; Chivers, G; Hooper, J M; Begg, S; Curtis, L

2006-01-01

The purpose of the study was to assess the prevalence and extent of missed peritoneal dialysis (PD) exchanges and to identify possible predictors for regimen modification. The study was a cross sectional postal survey of PD patients. Patients were asked to complete a single questionnaire looking at factors that influenced their management of the prescribed regimen. 551 patients were invited to participate in the study from 17 centres across three European countries; 10 centres from Belgium, 5 from Italy and 2 from the UK. Patients on continuous ambulatory peritoneal dialysis (CAPD), CAPD and Quantum, or automated peritoneal dialysis (APD) for more than three months and at least 18 years old were included in the study. 376 out of 551 questionnaires were completed; a response rate of 68%. 20% (n=67) of those who responded to the questionnaire admitted to modifying their treatment in the previous month. Those who were more likely to modify their treatment were younger, employed, had greater contact with the PD team, were on APD 10 hours or longer and were less satisfied with their APD treatment. Many of the patients self-reported modifying their dialysis regimen and possible predictors were highlighted from this study. By trying to identifying individual patients who do modify treatment healthcare professionals can target information that can support the patient in making safer treatment modification choices.

Propensity-Matched Mortality Comparison of Incident Hemodialysis and Peritoneal Dialysis Patients

PubMed Central

Weinhandl, Eric D.; Gilbertson, David T.; Arneson, Thomas J.; Snyder, Jon J.; Collins, Allan J.

2010-01-01

Contemporary comparisons of mortality in matched hemodialysis and peritoneal dialysis patients are lacking. We aimed to compare survival of incident hemodialysis and peritoneal dialysis patients by intention-to-treat analysis in a matched-pair cohort and in subsets defined by age, cardiovascular disease, and diabetes. We matched 6337 patient pairs from a retrospective cohort of 98,875 adults who initiated dialysis in 2003 in the United States. In the primary intention-to-treat analysis of survival from day 0, cumulative survival was higher for peritoneal dialysis patients than for hemodialysis patients (hazard ratio 0.92; 95% CI 0.86 to 1.00, P = 0.04). Cumulative survival probabilities for peritoneal dialysis versus hemodialysis were 85.8% versus 80.7% (P < 0.01), 71.1% versus 68.0% (P < 0.01), 58.1% versus 56.7% (P = 0.25), and 48.4% versus 47.3% (P = 0.50) at 12, 24, 36, and 48 months, respectively. Peritoneal dialysis was associated with improved survival compared with hemodialysis among subgroups with age <65 years, no cardiovascular disease, and no diabetes. In a sensitivity analysis of survival from 90 days after initiation, we did not detect a difference in survival between modalities overall (hazard ratio 1.05; 95% CI 0.96 to 1.16), but hemodialysis was associated with improved survival among subgroups with cardiovascular disease and diabetes. In conclusion, despite hazard ratio heterogeneity across patient subgroups and nonconstant hazard ratios during the follow-up period, the overall intention-to-treat mortality risk after dialysis initiation was 8% lower for peritoneal dialysis than for matched hemodialysis patients. These data suggest that increased use of peritoneal dialysis may benefit incident ESRD patients. PMID:20133483

Periodontal treatment reduces chronic systemic inflammation in peritoneal dialysis patients.

PubMed

Siribamrungwong, Monchai; Yothasamutr, Kasemsuk; Puangpanngam, Kutchaporn

2014-06-01

Chronic systemic inflammation, a non traditional risk factor of cardiovascular diseases, is associated with increasing mortality in chronic kidney disease, especially peritoneal dialysis patients. Periodontitis is a potential treatable source of systemic inflammation in peritoneal dialysis patients. Clinical periodontal status was evaluated in 32 stable chronic peritoneal dialysis patients by plaque index and periodontal disease index. Hematologic, blood chemical, nutritional, and dialysis-related data as well as highly sensitive C-reactive protein were analyzed before and after periodontal treatment. At baseline, high sensitive C-reactive protein positively correlated with the clinical periodontal status (plaque index; r = 0.57, P < 0.01, periodontal disease index; r = 0.56, P < 0.01). After completion of periodontal therapy, clinical periodontal indexes were significantly lower and high sensitivity C-reactive protein significantly decreased from 2.93 to 2.21 mg/L. Moreover, blood urea nitrogen increased from 47.33 to 51.8 mg/dL, reflecting nutritional status improvement. Erythropoietin dosage requirement decreased from 8000 to 6000 units/week while hemoglobin level was stable. Periodontitis is an important source of chronic systemic inflammation in peritoneal dialysis patients. Treatment of periodontal diseases can improve systemic inflammation, nutritional status and erythropoietin responsiveness in peritoneal dialysis patients. © 2013 The Authors. Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis.

Absolute and Relative Carnitine Deficiency in Patients on Hemodialysis and Peritoneal Dialysis.

PubMed

Naseri, Mitra; Mottaghi Moghadam Shahri, Hasan; Horri, Mohsen; Esmaeeli, Mohammad; Ghaneh Sherbaf, Fatemeh; Jahanshahi, Shohre; Moeenolroayaa, Giti; Rasoli, Zahra; Salemian, Farzaneh; Pour Hasan, Maryam

2016-01-01

Carnitine deficiency is commonly seen in dialysis patients. This study assessed the association dialysis and pediatric patients' characteristics with plasma carnitines levels. Plasma carnitine concentrations were measured by tandem mass spectrometry in 46 children on hemodialysis or peritoneal dialysis. The total carnitine, free carnitine (FC), and L-acyl carnitine (AC) levels of 40 µmol/L and less, less than 7 µmol/L, and less than 15 µmol/L were defined low, respectively. An FC less than 20 µmol/L and an AC/FC ratio greater than 0.4 were considered as absolute and relative carnitine deficiencies. The correlation between carnitines levels and AC/FC ratio and age, duration of dialysis, characteristics of dialysis, and blood urea nitrogen and serum albumin concentrations were assessed. Absolute carnitine deficiency, low total carnitine, and low AC concentrations were found in 66.7%, 82.6%, and 51% of the patients, respectively. All of the patients had relative carnitine deficiency. Carnitine measurements were not significantly different between the hemodialysis and peritoneal dialysis groups. More severe relative carnitine deficiency was found in those with lower blood urea nitrogen levels and those on peritoneal dialysis. No linear correlation was found between carnitine levels and age, duration of dialysis, characteristics of dialysis, serum albumin level, or blood urea nitrogen level. Absolute and relative carnitine deficiencies are common among children on dialysis. Patients with lower blood urea nitrogen levels and peritoneal dialysis patients are more prone to severe relative carnitine deficiency.

[Assessment of dietary habits in hemodialysis and peritoneal dialysis patients].

PubMed

Kardasz, Małgorzata; Małyszko, Jacek; Stefańska, Ewa; Ostrowska, Lucyna

2011-01-01

Adherence to a proper diet has a vast impact on the correct course of dialyses, wellbeing, and the results of some laboratory investigations in patients with declining renal failure. The nutritional status of dialysis patients is closely related to food and specific nutrients intake. The aim of study was assessment of dietary habits in dialysis patients. The study included 27 patients peritoneal dialysis (PD) and 92 hemodialysis (HD). In all of dialysis patients the following measurements were taken: body weight and height. The food intake was assessed by 24-hour dietary recall, (according to nutritional components). The portion size was estimated on the "Album of portions of products and dishes". The results were compared with dietary recommendations for dialysis patients and analyzed by computer software Dietetic 2 designed in the Institute of Food and Nutrition in Warsaw but computer program Statistica 7.0 was used for calculations. In all studied dialysis patients an irregular diet were observed. The diet was characterized by a low energetic value and low intake of proteins, carbohydrates, fiber and calcium, as well as by a too high fats. Among women's and man's in both groups were noted underweight: (W in PD patients--7%, M in DO patients--8%, W in HD patients--4%), overweight (W in PD patients--33%, M in DO patients--25%, W in HD patients--38%, M in HD patients--36%) and obesity (W in PD patients--26%, M in DO patients--33%, W in HD patients--22%, M in HD patients--21%). The study revealed that the daily food rations of peritoneal dialysis women were found to have a significantly higher the average intake dietary fiber (18.3 +/- 5.5 g/day) and higher potassium intake (2758.5 +/- 787.5 mg/day) as compared to the average intake dietary fiber (11.7 +/- 5.4 g/ day; p < 0.0001) and potassium intake (1612.9 +/- 822.9 mg/day; p < 0.0001) of hemodialysis women. The regular dietician advice is necessary for monitoring of patients nutrition.

Dialysis exercise team: the way to sustain exercise programs in hemodialysis patients.

PubMed

Capitanini, Alessandro; Lange, Sara; D'Alessandro, Claudia; Salotti, Emilio; Tavolaro, Alba; Baronti, Maria E; Giannese, Domenico; Cupisti, Adamasco

2014-01-01

Patients affected by end-stage renal disease (ESRD) show quite lower physical activity and exercise capacity when compared to healthy individuals. In addition, a sedentary lifestyle is favoured by lack of a specific counseling on exercise implementation in the nephrology care setting. Increasing physical activity level should represent a goal for every dialysis patient care management. Three crucial elements of clinical care may contribute to sustain a hemodialysis exercise program: a) involvement of exercise professionals, b) real commitment of nephrologists and dialysis professionals, c) individual patient adaptation of the exercise program. Dialysis staff have a crucial role to encourage and assist patients during intra-dialysis exercise, but other professionals should be included in the ideal "exercise team" for dialysis patients. Evaluation of general condition, comorbidities (especially cardiovascular), nutritional status and physical exercise capacity are mandatory to propose an exercise program, in either extra-dialysis or intra-dialysis setting. To this aim, nephrologist should lead a team of specialists and professionals including cardiologist, physiotherapist, exercise physiologist, renal dietician and nurse. In this scenario, dialysis nurses play a pivotal role since they guarantee a constant and direct approach. Unfortunately dialysis staff may often lack of information and formation about exercise management while they take care patients during the dialysis session. Building an effective exercise team, promoting the culture of exercise and increasing physical activity levels lead to a more complete and modern clinical care management of ESRD patients. © 2014 S. Karger AG, Basel.

Palliative peritoneal dialysis: Implementation of a home care programme for terminal patients treated with peritoneal dialysis (PD).

PubMed

Gorrin, Maite Rivera; Teruel-Briones, José Luis; Vion, Victor Burguera; Rexach, Lourdes; Quereda, Carlos

2015-01-01

Terminal-stage patients on peritoneal dialysis (PD) are often transferred to haemodialysis as they are unable to perform the dialysis technique themselves since their functional capacities are reduced. We present our experience with five patients on PD with a shortterm life-threatening condition, whose treatment was shared by primary care units and who were treated with a PD modality adapted to their circumstances, which we call Palliative Peritoneal Dialysis. Copyright © 2015. Published by Elsevier España, S.L.U.

Con: Higher serum bicarbonate in dialysis patients is protective.

PubMed

Chauveau, Philippe; Rigothier, Claire; Combe, Christian

2016-08-01

Metabolic acidosis is often observed in advanced chronic kidney disease, with deleterious consequences on the nutritional status, bone and mineral status, inflammation and mortality. Through clearance of the daily acid load and a net gain in alkaline buffers, dialysis therapy is aimed at correcting metabolic acidosis. A normal bicarbonate serum concentration is the recommended target in dialysis patients. However, several studies have shown that a mild degree of metabolic acidosis in patients treated with dialysis is associated with better nutritional status, higher protein intake and improved survival. Conversely, a high bicarbonate serum concentration is associated with poor nutritional status and lower survival. It is likely that mild acidosis results from a dietary acid load linked to animal protein intake. In contrast, a high bicarbonate concentration in patients treated with dialysis could result mainly from an insufficient dietary acid load, i.e. low protein intake. Therefore, a high pre-dialysis serum bicarbonate concentration should prompt nephrologists to carry out nutritional investigations to detect insufficient dietary protein intake. In any case, a high bicarbonate concentration should be neither a goal of dialysis therapy nor an index of adequate dialysis, whereas mild acidosis could be considered as an indicator of appropriate protein intake. © The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Cinacalcet in peritoneal dialysis patients: one-center experience.

PubMed

Conde, Sara Querido; Branco, Patrícia; Sousa, Henrique; Adragão, Teresa; Gaspar, Augusta; Barata, José Diogo

2017-03-01

Secondary hyperparathyroidism is the target of several therapeutic strategies, including the use of cinacalcet. Most studies were done only in hemodialysis patients, with few data from peritoneal dialysis patients. The aim of our work was to evaluate the effectiveness of cinacalcet in secondary hyperparathyroidism in a one-center peritoneal dialysis patients. A retrospective study was performed in 27 peritoneal dialysis patients with moderate to severe secondary hyperparathyroidism (PTHi > 500 pg/mL with normal or elevated serum calcium levels) treated with cinacalcet. Demographic, clinical and laboratory parameters at the beginning of cinacalcet therapy, second, fourth, sixth months after and at the time it was finished were analyzed. Patients were under peritoneal dialysis at 30.99 ± 16.58 months and were treated with cinacalcet for 15.6 ± 13.4 months; 21 (77.8%) patients showed adverse gastrointestinal effects; PTHi levels at the beginning of cinacalcet therapy were 1145 ± 449 pg/mL. The last PTHi levels under cinacalcet therapy was 1131 ± 642 pg/mL. PTHi reduction was statistically significant at 2 months after the beginning of cinacalcet (p = 0.007) but not in the following evaluations. It is necessary the development of new forms of cinacalcet presentation, in order to avoid gastrointestinal effects adverse factors and to improve therapeutic adherence.

Relationship between cognitive impairment and depression in dialysis patients.

PubMed

Jung, San; Lee, Young-Ki; Choi, Sun Ryoung; Hwang, Sung-Hee; Noh, Jung-Woo

2013-11-01

Patients with chronic kidney disease frequently show cognitive dysfunction. The association of depression and cognitive function is not well known in maintenance dialysis patients. We evaluated cognitive impairment and depression, as well as their relationship in regards to methods of dialysis, maintenance hemodialysis (MHD) and chronic peritoneal dialysis (CPD). Fifty-six maintenance dialysis patients were recruited and their clinical and laboratory data were collected. The Korean version of the mini-mental state exam (K-MMSE) was applied to screen the patient's cognitive function, while the Korean version of the Beck Depression Inventory (K-BDI) was used for depression screening. The average age of the participants was 54.2±10.2 years; 29 (51.8%) were female. The average dialysis vintage was 4.2±3.8 years. The CPD group showed significantly higher K-MMSE score (27.8±2.9 vs. 26.1±3.1, p=0.010) and lower K-BDI score (12.0±8.4 vs. 20.2±10.4, p=0.003) compared with the MHD group. The percentage of patients with depression symptoms was higher in the MHD group (51.7% vs. 18.5%). There was a negative correlation between cognitive function and prevalence of depressive symptoms. Depression and education level were shown to be independent predictors for cognitive impairment in multivariate analysis. Cognitive impairment was closely correlated with depression. It is important to detect cognitive impairment and depression early in maintenance dialysis patients with simple bedside screening tools.

Relationship between Cognitive Impairment and Depression in Dialysis Patients

PubMed Central

Jung, San; Choi, Sun Ryoung; Hwang, Sung-Hee; Noh, Jung-Woo

2013-01-01

Purpose Patients with chronic kidney disease frequently show cognitive dysfunction. The association of depression and cognitive function is not well known in maintenance dialysis patients. We evaluated cognitive impairment and depression, as well as their relationship in regards to methods of dialysis, maintenance hemodialysis (MHD) and chronic peritoneal dialysis (CPD). Materials and Methods Fifty-six maintenance dialysis patients were recruited and their clinical and laboratory data were collected. The Korean version of the mini-mental state exam (K-MMSE) was applied to screen the patient's cognitive function, while the Korean version of the Beck Depression Inventory (K-BDI) was used for depression screening. Results The average age of the participants was 54.2±10.2 years; 29 (51.8%) were female. The average dialysis vintage was 4.2±3.8 years. The CPD group showed significantly higher K-MMSE score (27.8±2.9 vs. 26.1±3.1, p=0.010) and lower K-BDI score (12.0±8.4 vs. 20.2±10.4, p=0.003) compared with the MHD group. The percentage of patients with depression symptoms was higher in the MHD group (51.7% vs. 18.5%). There was a negative correlation between cognitive function and prevalence of depressive symptoms. Depression and education level were shown to be independent predictors for cognitive impairment in multivariate analysis. Conclusion Cognitive impairment was closely correlated with depression. It is important to detect cognitive impairment and depression early in maintenance dialysis patients with simple bedside screening tools. PMID:24142650

The economic considerations of patients and caregivers in choice of dialysis modality

PubMed Central

Howard, Kirsten; Tong, Allison; Palmer, Suetonia C.; Marshall, Mark R.; Morton, Rachael L.

2016-01-01

Abstract Introduction Broader adoption of home dialysis could lead to considerable cost savings for health services. Globally, however, uptake remains low. The aim of this study was to describe patient and caregiver perspectives of the economic considerations that influence dialysis modality choice, and elicit policy‐relevant recommendations. Methods Semistructured interviews with predialysis or dialysis patients and their caregivers, at three hospitals in New Zealand. Interview transcripts were analyzed thematically. Findings 43 patients and 9 caregivers (total n = 52) participated. The three themes related to economic considerations were: (i) productivity losses associated with changes in employment; (ii) the need for personal subsidization of home dialysis expenses; and (iii) the role of socio‐economic disadvantage as a barrier to home dialysis. Patients weighed the flexibility of home dialysis which allowed them to remain employed, against time required for training and out‐of‐pocket costs. Patients saw the lack of reimbursement of home dialysis costs as unjust and suggested that reimbursement would incentivize home dialysis uptake. Social disadvantage was a barrier to home dialysis as patients’ housing was often unsuitable; they could not afford the additional treatment costs. Home hemodialysis was considered to have the highest out‐of‐pocket costs and was sometimes avoided for this reason. Discussion Our data suggests that economic considerations underpin the choices patients make about dialysis treatments, however these are rarely reported. To promote home dialysis, strategies to improve employment retention and housing, and to minimize out‐of‐pocket costs, need to be addressed directly by healthcare providers and payers. PMID:27196634

[How can we improve symptomatic hypotension in hemodialysis patients: cold dialysis vs isothermic dialysis].

PubMed

Ramos, R; Soto, C; Mestres, R; Jara, J; Zequera, H; Merello, J I; Moreso, F

2007-01-01

Symptomatic hypotension is the most frequent acute complication affecting patients during chronic hemodialysis treatment sessions. Many reports have demonstrated that the use of cool dialysate has a protective effect on blood pressure during hemodialysis treatments. In the present study, we investigated whether preventing the hyperthermic response had favourable effects on hemodynamic stability during the hemodialysis procedure while affording good tolerance to patients. We investigated the effect of thermal control of dialysate on hemodynamic stability in hypotension-prone patients in our center. Patients were eligible for the study if they had symptomatic hypotensive episodes (> 3/12session/ month) during the screening phase. The study was designed with two phases for the same selected patients and two treatment arms, each phase lasting 4 weeks. In the first phase, we adjusted dialysate temperature on 36 masculineC for 12 sessions (cold dialysis) and in the second phase we used a device allowing the regulation of thermal balance (Blood Temperature Monitor; Fresenius Medical Care, Bad Homberg, Germany), that keep body temperature unchanged (isothermic dialysis). Nine HD patients were enrolled and completed the study. During the screening phase the mean ultrafiltration was 4 1% of dry weight, and blood pressure decreased from 9916 to 8016 mm Hg (p<0.001). In 5.01.7 sessions of 12 treatments were complicated by hypotension. In the first and second phase we observed a decrease of complicated treatments with symptomatic hypotension (5.01.7 versus 2.71.6 y 2.81.7; p<0.01). Both procedures: Cold dialysis and Isothermic dialysis was well tolerated by patients. Results show that active control of body temperature can significantly improve intradialytic tolerance in hypotension-prone patients.

Effects of Different Models of Dialysis Care on Patient-Important Outcomes: A Systematic Review and Meta-Analysis.

PubMed

Ramar, Priya; Ahmed, Ahmed T; Wang, Zhen; Chawla, Sagar S; Suarez, Maria Lourdes Gonzalez; Hickson, LaTonya J; Farrell, Ann; Williams, Amy W; Shah, Nilay D; Murad, M Hassan; Thorsteinsdottir, Bjorg

2017-12-01

Ongoing payment reform in dialysis necessitates better patient outcomes and lower costs. Suggested improvements to processes of care for maintenance dialysis patients are abundant; however, their impact on patient-important outcomes is unclear. This systematic review included comparative randomized controlled trials or observational studies with no restriction on language, published from 2000 to 2014, involving at least 5 adult dialysis patients who received a minimum of 6 months of follow-up. The effect size was pooled and stratified by intervention strategy (multidisciplinary care [MDC], home dialysis, alternate dialysis settings, and electronic health record implementation). Heterogeneity (I 2 ) was used to assess the variability in study effects related to study differences rather than chance. Of the 1988 articles screened, 25 international studies with 74,833 maintenance dialysis patients were included. Interventions with MDC or home dialysis were associated with a lower mortality (hazard ratio [HR] = 0.72, 95% confidence interval [CI] 0.61, 0.84, I 2  = 41.6%; HR = 0.57, 95% CI 0.41, 0.81, I 2  = 89.0%; respectively) and hospitalizations (incidence rate ratio [IRR] = 0.68, 95% CI 0.51, 0.91, I 2  = NA; IRR = 0.88, 95% CI 0.64, 1.20, I 2  = 79.6%; respectively). Alternate dialysis settings also were associated with a reduction in hospitalizations (IRR = 0.41, 95% CI 0.25, 0.69, I 2  = 0.0%). This systematic review underscores the importance of multidisciplinary care, and also the value of telemedicine as a means to increase access to providers and enhance outcomes for those dialyzing at home or in alternate settings, including those with limited access to nephrology expertise because of travel distance.

Outpatient red blood cell transfusion payments among patients on chronic dialysis.

PubMed

Gitlin, Matthew; Lee, J Andrew; Spiegel, David M; Carson, Jeffrey L; Song, Xue; Custer, Brian S; Cao, Zhun; Cappell, Katherine A; Varker, Helen V; Wan, Shaowei; Ashfaq, Akhtar

2012-11-02

Payments for red blood cell (RBC) transfusions are separate from US Medicare bundled payments for dialysis-related services and medications. Our objective was to examine the economic burden for payers when chronic dialysis patients receive outpatient RBC transfusions. Using Truven Health MarketScan® data (1/1/02-10/31/10) in this retrospective micro-costing economic analysis, we analyzed data from chronic dialysis patients who underwent at least 1 outpatient RBC transfusion who had at least 6 months of continuous enrollment prior to initial dialysis claim and at least 30 days post-transfusion follow-up. A conceptual model of transfusion-associated resource use based on current literature was employed to estimate outpatient RBC transfusion payments. Total payments per RBC transfusion episode included screening/monitoring (within 3 days), blood acquisition/administration (within 2 days), and associated complications (within 3 days for acute events; up to 45 days for chronic events). A total of 3283 patient transfusion episodes were included; 56.4% were men and 40.9% had Medicare supplemental insurance. Mean (standard deviation [SD]) age was 60.9 (15.0) years, and mean Charlson comorbidity index was 4.3 (2.5). During a mean (SD) follow-up of 495 (474) days, patients had a mean of 2.2 (3.8) outpatient RBC transfusion episodes. Mean/median (SD) total payment per RBC transfusion episode was $854/$427 ($2,060) with 72.1% attributable to blood acquisition and administration payments. Complication payments ranged from mean (SD) $213 ($168) for delayed hemolytic transfusion reaction to $19,466 ($15,424) for congestive heart failure. Payments for outpatient RBC transfusion episodes were driven by blood acquisition and administration payments. While infrequent, transfusion complications increased payments substantially when they occurred.

Satisfaction with care in peritoneal dialysis patients.

PubMed

Kirchgessner, J; Perera-Chang, M; Klinkner, G; Soley, I; Marcelli, D; Arkossy, O; Stopper, A; Kimmel, P L

2006-10-01

Patient satisfaction is an important aspect of dialysis care, only recently evaluated in clinical studies. We developed a tool to assess peritoneal dialysis (PD) customer satisfaction, and sought to evaluate and validate the Customer Satisfaction Questionnaire (CSQ), quantifying PD patient satisfaction. The CSQ included questions regarding administrative issues, Delivery Service, PD Training, Handling Requests, and transportation. The study was performed using interviews in all Hungarian Fresenius Medical Care dialysis centers offering PD. CSQ results were compared with psychosocial measures to identify if patient satisfaction was associated with perception of social support and illness burden, or depression. We assessed CSQ internal consistency and validity. Factor analysis explored potential underlying dimensions of the CSQ. One hundred and thirty-three patients treated with PD for end-stage renal disease for more than 3 months were interviewed. The CSQ had high internal consistency. There was high patient satisfaction with customer service. PD patient satisfaction scores correlated with quality of life (QOL) and social support measures, but not with medical or demographic factors, or depressive affect. The CSQ is a reliable tool to assess PD customer satisfaction. PD patient satisfaction is associated with perception of QOL. Efforts to improve customer satisfaction may improve PD patients' quantity as well as QOL.

Views of Canadian patients on or nearing dialysis and their caregivers: a thematic analysis.

PubMed

Barnieh, Lianne; King-Shier, Kathryn; Hemmelgarn, Brenda; Laupacis, Andreas; Manns, Liam; Manns, Braden

2014-01-01

Quality of life of patients receiving dialysis has been rated as poor. To synthesize the views of Canadian patients on or nearing dialysis, and those who care for them. Secondary analysis of a survey, distributed through dialysis centres, social media and the Kidney Foundation of Canada. Pan-Canadian convenience sample. Patients, their caregivers and health-care providers. Text responses to open-ended questions on topics relevant to end-stage renal disease. Statements related to needs, beliefs or feelings were identified, and were analysed by thematic content analysis. A total of 544 relevant statements from 189 respondents were included for the thematic content analysis. Four descriptive themes were identified through the content analysis: gaining knowledge, maintaining quality of life, sustaining psychosocial wellbeing and ensuring appropriate care. Respondents primarily identified a need for more information, better communication, increased psychosocial and financial support for patients and their families and a strong desire to maintain their previous lifestyle. Convenience sample; questions were originally asked with a different intent (to identify patient-important research issues). Patients on or nearing dialysis and their caregivers identified four major themes, gaining knowledge, maintaining quality of life, sustaining psychosocial wellbeing and ensuring appropriate care, several of which could be addressed by the health care system without requiring significant resources. These include the development of patient materials and resources, or sharing of existing resources across Canadian renal programs, along with adopting better communication strategies. Other concerns, such as the need for increased psychosocial and financial support, require consideration by health care funders.

Nutritional assessment of elderly patients on dialysis: pitfalls and potentials for practice.

PubMed

Rodrigues, Juliana; Cuppari, Lilian; Campbell, Katrina L; Avesani, Carla Maria

2017-11-01

The chronic kidney disease (CKD) population is aging. Currently a high percentage of patients treated on dialysis are older than 65 years. As patients get older, several conditions contribute to the development of malnutrition, namely protein energy wasting (PEW), which may be compounded by nutritional disturbances associated with CKD and from the dialysis procedure. Therefore, elderly patients on dialysis are vulnerable to the development of PEW and awareness of the identification and subsequent management of nutritional status is of importance. In clinical practice, the nutritional assessment of patients on dialysis usually includes methods to assess PEW, such as the subjective global assessment, the malnutrition inflammation score, and anthropometric and laboratory parameters. Studies investigating measures of nutritional status specifically tailored to the elderly on dialysis are scarce. Therefore, the same methods and cutoffs used for the general adult population on dialysis are applied to the elderly. Considering this scenario, the aim of this review is to discuss specific considerations for nutritional assessment of elderly patients on dialysis addressing specific shortcomings on the interpretation of markers, in addition to providing clinical practice guidance to assess the nutritional status of elderly patients on dialysis. © The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

The interview with a patient on dialysis: feeling, emotions and fears.

PubMed

Brunori, Francesco; Dozio, Beatrice; Colzani, Sara; Pozzi, Marco; Pisano, Lucia; Galassi, Andrea; Santorelli, Gennaro; Auricchio, Sara; Busnelli, Luisa; Di Carlo, Angela; Viganò, Monica; Calabrese, Valentina; Mariani, Laura; Mossa, Monica; Longoni, Stefania; Scanziani, Renzo

2016-01-01

This study has been performed in the Nephrology and Dialysis Unit, in Desio Hospital, Italy. The aim of this study is to evaluate, starting from research questions, which information is given to patient in the pre-dialysis colloquia for his/her chosen dialysis methods. Moreover, the study evaluated feelings, emotions and fears since the announcement of the necessity of dialysis treatment. The objective of the study was reached through the interview with patients on dialysis. The fact-finding survey was based on the tools of social research, as the semi-structured interview. Instead of using the questionnaire, even though it make it easier to collect larger set of data, the Authors decided to interview patients in person, since the interview allows direct patient contact and to build a relationship of trust with the interviewer, in order to allow patient explain better his/her feeling.

The Different Association between Serum Ferritin and Mortality in Hemodialysis and Peritoneal Dialysis Patients Using Japanese Nationwide Dialysis Registry

PubMed Central

Maruyama, Yukio; Yokoyama, Keitaro; Yokoo, Takashi; Shigematsu, Takashi; Iseki, Kunitoshi; Tsubakihara, Yoshiharu

2015-01-01

Background/Aims Monitoring of serum ferritin levels is widely recommended in the management of anemia among patients on dialysis. However, associations between serum ferritin and mortality are unclear and there have been no investigations among patients undergoing peritoneal dialysis (PD). Methods Baseline data of 191,902 patients on dialysis (age, 65 ± 13 years; male, 61.1%; median dialysis duration, 62 months) were extracted from a nationwide dialysis registry in Japan at the end of 2007. Outcomes, such as one-year mortality, were then evaluated using the registry at the end of 2008. Results Within one year, a total of 15,284 (8.0%) patients had died, including 6,210 (3.2%) cardiovascular and 2,707 (1.4%) infection-related causes. Higher baseline serum ferritin levels were associated with higher mortality rates among patients undergoing hemodialysis (HD). In contrast, there were no clear associations between serum ferritin levels and mortality among PD patients. Multivariate Cox regression analysis of HD patients showed that those in the highest serum ferritin decile group had higher rates of all-cause and cardiovascular mortality than those in the lowest decile group (hazard ratio [HR], 1.54; 95% confidence interval [CI], 1.31–1.81 and HR, 1.44; 95% CI, 1.13–1.84, respectively), whereas associations with infection-related mortality became non-significant (HR, 1.14; 95% CI, 0.79–1.65). Conclusions Using Japanese nationwide dialysis registry, higher serum ferritin values were associated with mortality not in PD patients but in HD patients. PMID:26599216

Dialysis in the elderly. New possibilities, new problems.

PubMed

Cassidy, M J D; Sims, R J A

2004-09-01

In the last 2 decades, there has been a phenomenal increase in the number of incident and prevalent elderly patients receiving renal replacement therapy (RRT) and this trend is likely to continue. This article reviews the changing demographics of the renal patient population and discusses the possible reasons for this. The profile of the older adult patient group is discussed, and specific demands and requirements of this patient group are explained. In particular, the authors concentrate on dialysis mode and vascular access; malnutrition; falls and fractures; cognitive impairment and depression and drugs and pain. It is clear that the ''old old'' can benefit significantly from dialysis despite an increasing burden of comorbidity and prognosis on dialysis is discussed. In order to properly inform patients about treatment options it is essential to provide information about prognosis. For some patients dialysis may not be the preferred option and for others withdrawal from dialysis may be appropriate. Nephrologists therefore also need to be familiar with end of life issues and palliative symptom control.

Peritonitis Due to Roseomonas fauriae in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis

PubMed Central

Bibashi, Evangelia; Sofianou, Danai; Kontopoulou, Konstantina; Mitsopoulos, Efstathios; Kokolina, Elisabeth

2000-01-01

Roseomonas is a newly described genus of pink-pigmented, nonfermentative, gram-negative bacteria that have been recognized as a cause of human infections. Roseomonas fauriae is a species rarely isolated from clinical specimens. We report the first known case of peritonitis caused by R. fauriae in a patient receiving continuous ambulatory peritoneal dialysis. PMID:10618142

Explore Transplant at Home: a randomized control trial of an educational intervention to increase transplant knowledge for Black and White socioeconomically disadvantaged dialysis patients.

PubMed

Waterman, Amy D; McSorley, Anna-Michelle M; Peipert, John D; Goalby, Christina J; Peace, Leanne J; Lutz, Patricia A; Thein, Jessica L

2015-08-28

Compared to others, dialysis patients who are socioeconomically disadvantaged or Black are less likely to receive education about deceased donor kidney transplant (DDKT) and living donor kidney transplant (LDKT) before they reach transplant centers, often due to limited availability of transplant education within dialysis centers. Since these patients are often less knowledgeable or ready to pursue transplant, educational content must be simplified, made culturally sensitive, and presented gradually across multiple sessions to increase learning and honor where they are in their decision-making about transplant. The Explore Transplant at Home (ETH) program was developed to help patients learn more about DDKT and LDKT at home, with and without telephone conversations with an educator. In this randomized controlled trial (RCT), 540 low-income Black and White dialysis patients with household incomes at or below 250 % of the federal poverty line, some of whom receive financial assistance from the Missouri Kidney Program, will be randomly assigned to one of three education conditions: (1) standard-of-care transplant education provided by the dialysis center, (2) patient-guided ETH (ETH-PG), and (3) health educator-guided ETH (ETH-EG). Patients in the standard-of-care condition will only receive education provided in their dialysis centers. Those in the two ETH conditions will receive four video and print modules delivered over an 8 month period by mail, with the option of receiving supplementary text messages weekly. In addition, patients in the ETH-EG condition will participate in multiple telephonic educational sessions with a health educator. Changes in transplant knowledge, decisional balance, self-efficacy, and informed decision making will be captured with surveys administered before and after the ETH education. At the conclusion of this RCT, we will have determined whether an education program administered to socioeconomically disadvantaged dialysis patients

Prognostic Value of Residual Urine Volume, GFR by 24-hour Urine Collection, and eGFR in Patients Receiving Dialysis.

PubMed

Lee, Mi Jung; Park, Jung Tak; Park, Kyoung Sook; Kwon, Young Eun; Oh, Hyung Jung; Yoo, Tae-Hyun; Kim, Yong-Lim; Kim, Yon Su; Yang, Chul Woo; Kim, Nam-Ho; Kang, Shin-Wook; Han, Seung Hyeok

2017-03-07

Residual kidney function can be assessed by simply measuring urine volume, calculating GFR using 24-hour urine collection, or estimating GFR using the proposed equation (eGFR). We aimed to investigate the relative prognostic value of these residual kidney function parameters in patients on dialysis. Using the database from a nationwide prospective cohort study, we compared differential implications of the residual kidney function indices in 1946 patients on dialysis at 36 dialysis centers in Korea between August 1, 2008 and December 31, 2014. Residual GFR calculated using 24-hour urine collection was determined by an average of renal urea and creatinine clearance on the basis of 24-hour urine collection. eGFR-urea, creatinine and eGFR β 2 -microglobulin were calculated from the equations using serum urea and creatinine and β 2 -microglobulin, respectively. The primary outcome was all-cause death. During a mean follow-up of 42 months, 385 (19.8%) patients died. In multivariable Cox analyses, residual urine volume (hazard ratio, 0.96 per 0.1-L/d higher volume; 95% confidence interval, 0.94 to 0.98) and GFR calculated using 24-hour urine collection (hazard ratio, 0.98; 95% confidence interval, 0.95 to 0.99) were independently associated with all-cause mortality. In 1640 patients who had eGFR β 2 -microglobulin data, eGFR β 2 -microglobulin (hazard ratio, 0.98; 95% confidence interval, 0.96 to 0.99) was also significantly associated with all-cause mortality as well as residual urine volume (hazard ratio, 0.96 per 0.1-L/d higher volume; 95% confidence interval, 0.94 to 0.98) and GFR calculated using 24-hour urine collection (hazard ratio, 0.97; 95% confidence interval, 0.95 to 0.99). When each residual kidney function index was added to the base model, only urine volume improved the predictability for all-cause mortality (net reclassification index =0.11, P =0.01; integrated discrimination improvement =0.01, P =0.01). Higher residual urine volume was significantly

Effect of dialysis modality on frailty phenotype, disability, and health-related quality of life in maintenance dialysis patients

PubMed Central

Kang, Seok Hui; Do, Jun Young; Lee, So-Young; Kim, Jun Chul

2017-01-01

Background Health-related quality of life (HRQoL) surveys are needed to evaluate regional and ethnic specificies. The aim of the present study was to evaluate the differences in HRQoL, frailty, and disability according to dialysis modality in the Korean population. Patients and methods We enrolled relatively stable maintenance dialysis patients. A total of 1,616 patients were recruited into our study. The demographic and laboratory data collected at enrollment included age, sex, comorbidities, frailty, disability, and HRQoL scales. Results A total of 1,250 and 366 participants underwent hemodialysis (HD) and peritoneal dialysis (PD), respectively. The numbers of participants with pre-frailty and frailty were 578 (46.2%) and 422 (33.8%) in HD patients, and 165 (45.1%) and 137 (37.4%) in PD patients, respectively (P = 0.349). Participants with a disability included 195 (15.6%) HD patients and 109 (29.8%) PD patients (P < 0.001). On multivariate analysis, the mean physical component scale (PCS) and mental component scale (MCS), symptom/problems, and sleep scores were higher in HD patients than in PD patients. Cox regression analyses showed that an increased PCS in both HD and PD patients was positively associated with patient survival and first hospitalization–free survival. An increased MCS in both HD and PD patients was positively associated with first hospitalization–free survival only. Conclusion There was no significant difference in frailty between patients treated with the two dialysis modalities; however, disability was more common in PD patients than in HD patients. The MCS and PCS were more favorable in HD patients than in PD patients. Symptom/problems, sleep, quality of social interaction, and social support were more favorable in HD patients than in PD patients; however, patient satisfaction and dialysis staff encouragement were more favorable in PD patients than in HD patients. PMID:28467472

Effect of dialysis modality on frailty phenotype, disability, and health-related quality of life in maintenance dialysis patients.

PubMed

Kang, Seok Hui; Do, Jun Young; Lee, So-Young; Kim, Jun Chul

2017-01-01

Health-related quality of life (HRQoL) surveys are needed to evaluate regional and ethnic specificies. The aim of the present study was to evaluate the differences in HRQoL, frailty, and disability according to dialysis modality in the Korean population. We enrolled relatively stable maintenance dialysis patients. A total of 1,616 patients were recruited into our study. The demographic and laboratory data collected at enrollment included age, sex, comorbidities, frailty, disability, and HRQoL scales. A total of 1,250 and 366 participants underwent hemodialysis (HD) and peritoneal dialysis (PD), respectively. The numbers of participants with pre-frailty and frailty were 578 (46.2%) and 422 (33.8%) in HD patients, and 165 (45.1%) and 137 (37.4%) in PD patients, respectively (P = 0.349). Participants with a disability included 195 (15.6%) HD patients and 109 (29.8%) PD patients (P < 0.001). On multivariate analysis, the mean physical component scale (PCS) and mental component scale (MCS), symptom/problems, and sleep scores were higher in HD patients than in PD patients. Cox regression analyses showed that an increased PCS in both HD and PD patients was positively associated with patient survival and first hospitalization-free survival. An increased MCS in both HD and PD patients was positively associated with first hospitalization-free survival only. There was no significant difference in frailty between patients treated with the two dialysis modalities; however, disability was more common in PD patients than in HD patients. The MCS and PCS were more favorable in HD patients than in PD patients. Symptom/problems, sleep, quality of social interaction, and social support were more favorable in HD patients than in PD patients; however, patient satisfaction and dialysis staff encouragement were more favorable in PD patients than in HD patients.

[Assisted peritoneal dialysis: home-based renal replacement therapy for the elderly patient].

PubMed

Wiesholzer, Martin

2013-06-01

The number of elderly patients with end stage renal disease is constantly increasing. Conventional hämodiaylsis as the mainstay of renal replacement therapy is often poorly tolerated by frail eldery patients with multiple comorbidities. Although many of these patients would prefer a home based dialysis treatment, the number of elderly patients using peritoneal dialysis (PD) is still low. Impaired physical and cognitive function often generates insurmountable barriers for self care peritoneal dialysis. Assisted peritoneal dialysis can overcome many of these barriers and give elderly patients the ability of a renal replacement therapy in their own homes respecting their needs.

Vascular access in patients receiving hemodialysis in Libya.

PubMed

Alashek, Wiam A; McIntyre, Christopher W; Taal, Maarten W

2012-01-01

A native arteriovenous fistula (AVF) represents the optimal form of Vascular Access (VA) for patients receiving hemodialysis (HD). In Libya there are several barriers to AVF creation including lack of adequate preparation for dialysis and surgical services. We aimed to conduct the first comprehensive study of VA utilisation in HD patients in Libya. A prospective observational study included all adult patients receiving HD treatment in 25 HD facilities in Libya from May 2009 to Nov 2011. Researchers gathered data regarding VA through interviews with staff and patients as well as medical records. Patients with definitive VA were re-interviewed after 1 year. At baseline the majority of patients (91.9%; n=1573) were using permanent VA in the form of AVF or arteriovenous graft. Patients with permanent VA were more likely to be male and less likely to be diabetic than those with CVCs. Most patients had commenced HD using a temporary CVC (91.8%). VA-related complications were: thrombosis (46.7%), aneurysm (22.6%), infection (11.5%) and haemorrhage (10.2%). Incident VA thrombosis was reported by 14.7% in 1 year. Independent risk factors for incident thrombosis were female gender and diabetes. Hospitalisation for VA related complications was reported by 31.4%. Few patients in Libya initiate HD with definitive VA, but most achieve it thereafter. Improved dialysis preparation and increased provision of surgical services are required to increase the proportion of patients initiating HD with definitive VA and should be a priority in rebuilding health services in Libya after the recent conflict.

Patient Acceptability of the Yorkshire Dialysis Decision Aid (YoDDA) Booklet: A Prospective Non-Randomized Comparison Study Across 6 Predialysis Services.

PubMed

Winterbottom, Anna E; Gavaruzzi, Teresa; Mooney, Andrew; Wilkie, Martin; Davies, Simon J; Crane, Dennis; Tupling, Ken; Baxter, Paul D; Meads, David M; Mathers, Nigel; Bekker, Hilary L

2016-01-01

♦ Patients are satisfied with their kidney care but want more support in making dialysis choices. Predialysis leaflets vary across services, with few being sufficient to enable patients' informed decision making. We describe the acceptability of a patient decision aid and feasibility of evaluating its effectiveness within usual predialysis practice. ♦ Prospective non-randomized comparison design, Usual Care or Usual Care Plus Yorkshire Dialysis Decision Aid Booklet (+YoDDA), in 6 referral centers (Yorkshire-Humber, UK) for patients with sustained deterioration of kidney function. Consenting (C) patients completed questionnaires after predialysis consultation (T1), and 6 weeks later (T2). Measures assessed YoDDA's utility to support patients' decisions and integration within usual care. ♦ Usual Care (n = 105) and +YoDDA (n = 84) participant characteristics were similar: male (62%), white (94%), age (mean = 62.6; standard deviation [SD] 14.4), kidney disease severity (glomerular filtration rate [eGFR] mean = 14.7; SD 3.7); decisional conflict was < 25; choice-preference for home versus hospital dialysis approximately 50:50. Patients valued receiving YoDDA, reading it on their own (96%), and sharing it with family (72%). The +YoDDA participants had higher scores for understanding kidney disease, reasoning about options, feeling in control, sharing their decision with family. Study engagement varied by center (estimated range 14 - 49%; mean 45%); participants varied in completion of decision quality measures. ♦ Receiving YoDDA as part of predialysis education was valued and useful to patients with worsening kidney disease. Integrating YoDDA actively within predialysis programs will meet clinical guidelines and patient need to support dialysis decision making in the context of patients' lifestyle. Copyright © 2016 International Society for Peritoneal Dialysis.

Restless legs syndrome in dialysis patients: a comparison between hemodialysis and continuous ambulatory peritoneal dialysis.

PubMed

Merlino, Giovanni; Lorenzut, Simone; Romano, Giulio; Sommaro, Martina; Fontana, Augusto; Montanaro, Domenico; Valente, Mariarosaria; Gigli, Gian Luigi

2012-12-01

Restless legs syndrome (RLS) is common in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD). A few studies so far have investigated RLS prevalence in ESRD patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The aim of this study was to compare the prevalence, characteristics, consequences and predictors of RLS between HD and CAPD patients. We recruited 58 HD and 28 CAPD patients. A neurologist expert in sleep medicine performed RLS diagnosis during a face-to-face interview. The prevalence of RLS was slightly higher in HD than in CAPD patients (19 vs. 10.7%). RLS appeared after the onset of kidney complaint in HD patients; in contrast, in CAPD patients RLS preceded the occurrence of renal disease. Five HD patients reported that RLS symptoms occurred throughout the dialysis session. HD patients with RLS(+) had a higher mean number of HD sessions per week and a longer mean duration of HD session than the RLS(-) ones. Prevalence of females was significantly higher in CAPD patients with RLS(+) than in the RLS(-) ones. RLS frequently affects both HD and CAPD patients. RLS impaired sleep in both groups, but use of dopaminergic agents was uncommon in our sample. Dialysis schedule was associated with RLS in HD patients, while female sex was related to RLS in CAPD patients. Awareness concerning RLS identification and treatment in HD and CAPD patients is recommended.

Nutritional evaluation of patients receiving dialysis for the management of protein-energy wasting: what is old and what is new?

PubMed

Riella, Miguel C

2013-05-01

Advances in the nutritional support of hospitalized patients in the early 1970s led to the recognition that tools were needed to evaluate the nutritional status of patients. The observation that malnutrition in patients receiving dialysis was associated with increased morbidity and mortality prompted many expert groups to develop nutritional scoring systems to be applied in these patients. Given the diverse and confusing terminologies that emerged from these publications, the International Society of Renal Nutritional and Metabolism convened an expert panel to recommend a new nomenclature and preferred methods to evaluate the nutritional status of patients with chronic kidney disease (CKD). The new and inclusive term protein-energy wasting (PEW) refers to a systematically defined condition based on certain criteria and reflects malnutrition and wasting caused not only by inadequate nutrient intake but also by depletion resulting from the inflammatory and noninflammatory conditions that prevail in this population. Serial assessment of nutritional status for detection and management of PEW is recommended using old and new scoring tools, including the Subjective Global Assessment (SGA), malnutrition inflammation score (MIS), Geriatric Nutritional Risk Index (GNRI), and PEW definition criteria. These tools, which are reliable methods and predictors of outcomes, are reviewed in this article. Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Hydration Status of Patients Dialyzed with Biocompatible Peritoneal Dialysis Fluids

PubMed Central

Lichodziejewska-Niemierko, Monika; Chmielewski, Michał; Dudziak, Maria; Ryta, Alicja; Rutkowski, Bolesław

2016-01-01

♦ Background: Biocompatible fluids for peritoneal dialysis (PD) have been introduced to improve dialysis and patient outcome in end-stage renal disease. However, their impact on hydration status (HS), residual renal function (RRF), and dialysis adequacy has been a matter of debate. The aim of the study was to evaluate the influence of a biocompatible dialysis fluid on the HS of prevalent PD patients. ♦ Methods: The study population consisted of 18 prevalent PD subjects, treated with standard dialysis fluids. At baseline, 9 patients were switched to a biocompatible solution, low in glucose degradation products (GDPs) (Balance; Fresenius Medical Care, Bad Homburg, Germany). Hydration status was assessed through clinical evaluation, laboratory parameters, echocardiography, and bioimpedance spectroscopy over a 24-month observation period. ♦ Results: During the study period, urine volume decreased similarly in both groups. At the end of the evaluation, there were also no differences in clinical (body weight, edema, blood pressure), laboratory (N-terminal pro-brain natriuretic peptide, NTproBNP), or echocardiography determinants of HS. However, dialysis ultrafiltration decreased in the low-GDP group and, at the end of the study, equaled 929 ± 404 mL, compared with 1,317 ± 363 mL in the standard-fluid subjects (p = 0.06). Hydration status assessed by bioimpedance spectroscopy was +3.64 ± 2.08 L in the low-GDP patients and +1.47 ± 1.61 L in the controls (p = 0.03). ♦ Conclusions: The use of a low-GDP biocompatible dialysis fluid was associated with a tendency to overhydration, probably due to diminished ultrafiltration in prevalent PD patients. PMID:26475845

Differences in care burden of patients undergoing dialysis in different centres in the netherlands.

PubMed

de Kleijn, Ria; Uyl-de Groot, Carin; Hagen, Chris; Diepenbroek, Adry; Pasker-de Jong, Pieternel; Ter Wee, Piet

2017-06-01

A classification model was developed to simplify planning of personnel at dialysis centres. This model predicted the care burden based on dialysis characteristics. However, patient characteristics and different dialysis centre categories might also influence the amount of care time required. To determine if there is a difference in care burden between different categories of dialysis centres and if specific patient characteristics predict nursing time needed for patient treatment. An observational study. Two hundred and forty-two patients from 12 dialysis centres. In 12 dialysis centres, nurses filled out the classification list per patient and completed a form with patient characteristics. Nephrologists filled out the Charlson Comorbidity Index. Independent observers clocked the time nurses spent on separate steps of the dialysis for each patient. Dialysis centres were categorised into four types. Data were analysed using regression models. In contrast to other dialysis centres, academic centres needed 14 minutes more care time per patient per dialysis treatment than predicted in the classification model. No patient characteristics were found that influenced this difference. The only patient characteristic that predicted the time required was gender, with more time required to treat women. Gender did not affect the difference between measured and predicted care time. Differences in care burden were observed between academic and other centres, with more time required for treatment in academic centres. Contribution of patient characteristics to the time difference was minimal. The only patient characteristics that predicted care time were previous transplantation, which reduced the time required, and gender, with women requiring more care time. © 2017 European Dialysis and Transplant Nurses Association/European Renal Care Association.

A missed opportunity – consequences of unknown levetiracepam pharmacokinetics in a peritoneal dialysis patient

PubMed Central

2014-01-01

Background Levetiracetam is a frequently used drug in the therapy of partial onset, myoclonic and generalized tonic-clonic seizures. The main route of elimination is via the kidneys, which eliminate 66% of the unchanged drug as well as 24% as inactive metabolite that stems from enzymatic hydrolysis. Therefore dose adjustments are needed in patients with chronic kidney disease stage 5 D, i.e. patients undergoing dialysis treatment. In this patient population a dose reduction by 50% is recommended, so that patients receive 250–750 mg every 12 hours. However “dialysis” can be performed in using different modalities and treatment intensities. For most of the drugs pharmacokinetic data and dosing recommendations for patients undergoing peritoneal dialysis are not available. This is the first report on levetiracetam pharmacokinetics in a peritoneal dialysis patient. Case presentation A 73-y-old Caucasian male (height: 160 cm, weight 93 kg, BMI 36.3 kg/m2) was admitted with a Glasgow Coma Scale of 10. Due to diabetic and hypertensive nephropathy he was undergoing peritoneal dialysis for two years. Eight weeks prior he was put on levetiracetam 500 mg twice daily for suspected partial seizures with secondary generalization. According to the patient’s wife, levetiracetam lead to fatigue and somnolence leading to trauma with fracture of the metatarsal bone. Indeed, even 24 hours after discontinuation of levetiracetam blood level was still 29.8 mg/l (therapeutic range: 12 – 46 mg/l). Fatigue and stupor had disappeared five days after discontinuation of the levetiracepam. A single dose pharamockinetic after re-exposure showed an increased half life of 18.4 hours (normal half life 7 hours) and levetiracetam content in the peritoneal dialysate. Both half-life and dialysate content might help to guide dosing in this patient population. Conclusion If levetiracetam is used in peritoneal dialysis patients it should be regularly monitored to avoid supratherapeutic

Prevalence-Based Targets Underestimate Home Dialysis Program Activity and Requirements for Growth.

PubMed

Bevilacqua, Micheli U; Er, Lee; Copland, Michael A; Singh, R Suneet; Jamal, Abeed; Dunne, Órla Marie; Brumby, Catherine; Levin, Adeera

2018-01-01

Many renal programs have targets to increase home dialysis prevalence. Data from a large Canadian home dialysis program were analyzed to determine if home dialysis prevalence accurately reflects program activity and whether prevalence-based assessments adequately reflect the work required for program growth. Data from home dialysis programs in British Columbia, Canada, were analyzed from 2005 to 2015. Prevalence data were compared to dialysis activity data including intakes and exits to describe program turnover. Using current attrition rates, recruitment rates needed to increase home dialysis prevalence proportions were identified. We analyzed 7,746 patient-years of peritoneal dialysis (PD) and 1,362 patient-years of home hemodialysis (HHD). The proportion of patients on home dialysis increased by 3.34% over the ten years examined, while the number of prevalent home dialysis patients increased 2.65% per year and the number of patients receiving home dialysis at any time in the year increased 4.04% per year. For every 1 patient net home dialysis growth, 13.6 new patients were recruited. Patient turnover included higher rates of transplantation in home dialysis than facility-based HD. Overall, the proportion dialyzing at home increased from 29.3 to 32.6%. There is high patient turnover in home dialysis such that program prevalence is an incomplete marker of total program activity. This turnover includes high rates of transplantation, which is a desirable interaction that affects home dialysis prevalence. The shortcomings of this commonly used metric are important for renal programs to consider, and better understanding of the activities that support home dialysis and the complex trajectories that home dialysis patients follow is needed. Copyright © 2018 International Society for Peritoneal Dialysis.

Types of vicarious learning experienced by pre-dialysis patients.

PubMed

McCarthy, Kate; Sturt, Jackie; Adams, Ann

2015-01-01

Haemodialysis and peritoneal dialysis renal replacement treatment options are in clinical equipoise, although the cost of haemodialysis to the National Health Service is £16,411/patient/year greater than peritoneal dialysis. Treatment decision-making takes place during the pre-dialysis year when estimated glomerular filtration rate drops to between 15 and 30 mL/min/1.73 m(2). Renal disease can be familial, and the majority of patients have considerable health service experience when they approach these treatment decisions. Factors affecting patient treatment decisions are currently unknown. The objective of this article is to explore data from a wider study in specific relation to the types of vicarious learning experiences reported by pre-dialysis patients. A qualitative study utilised unstructured interviews and grounded theory analysis during the participant's pre-dialysis year. The interview cohort comprised 20 pre-dialysis participants between 24 and 80 years of age. Grounded theory design entailed thematic sampling and analysis, scrutinised by secondary coding and checked with participants. Participants were recruited from routine renal clinics at two local hospitals when their estimated glomerular filtration rate was between 15 and 30 mL/min/1.73 m(2). Vicarious learning that contributed to treatment decision-making fell into three main categories: planned vicarious leaning, unplanned vicarious learning and historical vicarious experiences. Exploration and acknowledgement of service users' prior vicarious learning, by healthcare professionals, is important in understanding its potential influences on individuals' treatment decision-making. This will enable healthcare professionals to challenge heuristic decisions based on limited information and to encourage analytic thought processes.

Outcomes following surgical management of femoral neck fractures in elderly dialysis-dependent patients.

PubMed

Puvanesarajah, Varun; Amin, Raj; Qureshi, Rabia; Shafiq, Babar; Stein, Ben; Hassanzadeh, Hamid; Yarboro, Seth

2018-06-01

Proximal femur fractures are one of the most common fractures observed in dialysis-dependent patients. Given the large comorbidity burden present in this patient population, more information is needed regarding post-operative outcomes. The goal of this study was to assess morbidity and mortality following operative fixation of femoral neck fractures in the dialysis-dependent elderly. The full set of medicare data from 2005 to 2014 was retrospectively analyzed. Elderly patients with femoral neck fractures were selected. Patients were stratified based on dialysis dependence. Post-operative morbidity and mortality outcomes were compared between the two populations. Adjusted odds were calculated to determine the effect of dialysis dependence on outcomes. A total of 320,629 patients met the inclusion criteria. Of dialysis-dependent patients, 1504 patients underwent internal fixation and 2662 underwent arthroplasty. For both surgical cohorts, dialysis dependence was found to be associated with at least 1.9 times greater odds of mortality within 1 and 2 years post-operatively. Blood transfusions within 90 days and infections within 2 years were significantly increased in the dialysis-dependent study cohort. Dialysis dependence alone did not contribute to increased mechanical failure or major medical complications. Regardless of the surgery performed, dialysis dependence is a significant risk factor for major post-surgical morbidity and mortality after operative treatment of femoral neck fractures in this population. Increased mechanical failure in the internal fixation group was not observed. The increased risk associated with caring for this population should be understood when considering surgical intervention and counseling patients.

Physical function was related to mortality in patients with chronic kidney disease and dialysis.

PubMed

Morishita, Shinichiro; Tsubaki, Atsuhiro; Shirai, Nobuyuki

2017-10-01

Previous studies have shown that exercise improves aerobic capacity, muscular functioning, cardiovascular function, walking capacity, and health-related quality of life (QOL) in patients with chronic kidney disease (CKD) and dialysis. Recently, additional studies have shown that higher physical activity contributes to survival and decreased mortality as well as physical function and QOL in patients with CKD and dialysis. Herein, we review the evidence that physical function and physical activity play an important role in mortality for patients with CKD and dialysis. During November 2016, Medline and Web of Science databases were searched for published English medical reports (without a time limit) using the terms "CKD" or "dialysis" and "mortality" in conjunction with "exercise capacity," "muscle strength," "activities of daily living (ADL)," "physical activity," and "exercise." Numerous studies suggest that higher exercise capacity, muscle strength, ADL, and physical activity contribute to lower mortality in patients with CKD and dialysis. Physical function is associated with mortality in patients with CKD and dialysis. Increasing physical function may decrease the mortality rate of patients with CKD and dialysis. Physicians and medical staff should recognize the importance of physical function in CKD and dialysis. In addition, exercise is associated with reduced mortality among patients with CKD and dialysis. © 2017 International Society for Hemodialysis.

Detrended Fluctuation Analysis of Heart Rate Dynamics Is an Important Prognostic Factor in Patients with End-Stage Renal Disease Receiving Peritoneal Dialysis

PubMed Central

Lin, Lian-Yu; Chang, Chin-Hao; Chu, Fang-Ying; Lin, Yen-Hung; Wu, Cho-Kai; Lee, Jen-Kuang; Hwang, Juei-Jen; Lin, Jiunn-Lee; Chiang, Fu-Tien

2016-01-01

Background and Objectives Patients with severe kidney function impairment often have autonomic dysfunction, which could be evaluated noninvasively by heart rate variability (HRV) analysis. Nonlinear HRV parameters such as detrended fluctuation analysis (DFA) has been demonstrated to be an important outcome predictor in patients with cardiovascular diseases. Whether cardiac autonomic dysfunction measured by DFA is also a useful prognostic factor in patients with end-stage renal disease (ESRD) receiving peritoneal dialysis (PD) remains unclear. The purpose of the present study was designed to test the hypothesis. Materials and Methods Patients with ESRD receiving PD were included for the study. Twenty-four hour Holter monitor was obtained from each patient together with other important traditional prognostic makers such as underlying diseases, left ventricular ejection fraction (LVEF) and serum biochemistry profiles. Short-term (DFAα1) and long-term (DFAα2) DFA as well as other linear HRV parameters were calculated. Results A total of 132 patients (62 men, 72 women) with a mean age of 53.7±12.5 years were recruited from July 2007 to March 2009. During a median follow-up period of around 34 months, eight cardiac and six non-cardiac deaths were observed. Competing risk analysis demonstrated that decreased DFAα1 was a strong prognostic predictor for increased cardiac and total mortality. ROC analysis showed that the AUC of DFAα1 (<0.95) to predict mortality was 0.761 (95% confidence interval (CI). = 0.617–0.905). DFAα1≧ 0.95 was associated with lower cardiac mortality (Hazard ratio (HR) 0.062, 95% CI = 0.007–0.571, P = 0.014) and total mortality (HR = 0.109, 95% CI = 0.033–0.362, P = 0.0003). Conclusion Cardiac autonomic dysfunction evaluated by DFAα1 is an independent predictor for cardiac and total mortality in patients with ESRD receiving PD. PMID:26828209

Pancreatitis: an important cause of abdominal symptoms in patients on peritoneal dialysis.

PubMed

Caruana, R J; Wolfman, N T; Karstaedt, N; Wilson, D J

1986-02-01

In an eight-month period, four patients in our peritoneal dialysis program developed acute pancreatitis, an incidence significantly higher than that in our hemodialysis program. Diagnosis was difficult since the symptoms of pancreatitis were similar to those of peritoneal dialysis-associated peritonitis. Further difficulties in diagnosis were due to unreliability of serum amylase levels and "routine" ultrasound examinations in suggesting the presence of pancreatitis. Computerized tomography performed in three patients showed enlarged, edematous pancreata with large extrapancreatic fluid collections in all cases. Two patients died, one directly due to complications of pancreatitis. One patient was changed to hemodialysis and showed clinical and radiologic resolution of his pancreatitis. One patient remains on peritoneal dialysis but has now had four attacks of acute pancreatitis. No patient had classic risk factors for development of pancreatitis. Review of patient histories showed no common historical factors except for renal failure itself, peritoneal dialysis, peritonitis, catheter surgery, and hypoproteinemia. It is possible that metabolic abnormalities related to absorption of glucose and buffer from dialysate or absorption of a toxic substance present in dialysate, bags, or tubing can cause pancreatitis in patients on peritoneal dialysis. We feel that a diagnosis of pancreatitis should be considered when peritoneal dialysis patients present with abdominal pain, particularly if peritoneal fluid cultures are negative or if patients with positive cultures do not have prompt resolution of symptoms with appropriate antibiotic therapy.

Hepatitis C virus and the immunological response to hepatitis B virus vaccine in dialysis patients: meta-analysis of clinical studies.

PubMed

Fabrizi, F; Dixit, V; Martin, P; Messa, P

2011-12-01

It is well known that the seroconversion rate of patients following hepatitis B virus (HBV) vaccination is lower in uraemic than healthy subjects. A variety of inherited or acquired factors have been implicated in this diminished response, and the high prevalence of hepatitis C virus (HCV) infection among patients on maintenance dialysis has been suggested to play a role. However, the impact of HCV on the immune response to HB vaccine in patients receiving long-term dialysis is not entirely understood. Here, we evaluate the influence of HCV infection on the immunological response to HBV vaccine in dialysis population by performing a systematic review of the literature with a meta-analysis of clinical studies.We used the random-effects model of DerSimonian and Laird with heterogeneity and sensitivity analyses. The end-point of interest was the rate of patients showing seroprotective anti-hepatitis B titres at completion of HBV vaccine schedule among HCV-positive versus HCV-negative patients on chronic dialysis. We identified eight studies involving 520 unique patients on long-term dialysis. Aggregation of study results did not show a significant decrease in response rates among HCV-infected versus noninfected patients [pooled odds ratio = 0.621 (95% CI, 0.285; 1.353)]. The P-value was 0.007 for our test of study heterogeneity. Stratified analysis in various subgroups of interest did not meaningfully change our results. Our meta-analysis showed no association between immunological response to hepatitis B vaccine and HCV infection in individuals on long-term dialysis. These results support the use of recombinant vaccine against hepatitis B in patients on regular dialysis with HCV infection. © 2011 Blackwell Publishing Ltd.

The Choice of Renal Replacement Therapy (CORETH) project: dialysis patients' psychosocial characteristics and treatment satisfaction.

PubMed

Robinski, Maxi; Mau, Wilfried; Wienke, Andreas; Girndt, Matthias

2017-02-01

Until today, research has underestimated the role of psychosocial conditions as contributing factors to dialysis modality choice. The novelty within the Choice of Renal Replacement Therapy (CORETH) project (German Clinical Trials Register #DRKS00006350) is its focus on the multivariate associations between these aspects and their consecutive significance regarding treatment satisfaction (TS) in peritoneal dialysis (PD) versus haemodialysis (HD) patients. In this article, we present the baseline results of a multicentre study, which is supported by a grant from the German Ministry for Education and Research. Six to 24 months after initiation of dialysis, 780 patients from 55 dialysis centres all over Germany were surveyed. The questionnaire addressed psychosocial, physical, socio-demographic and shared decision-making (SDM) aspects. Furthermore, cognitive functioning was tested. After indexing the measures, two propensity score-matched groups (n = 482) were compared in a first step, after having chosen PD or HD. In a second step, a moderated multiple regression (n = 445) was conducted to initially investigate the multivariate impact of patient characteristics on TS. In comparison with HD patients, PD patients were more satisfied with their treatment (P < 0.001), had a more autonomy-seeking personality (P = 0.04), had better cognitive functioning (P = 0.001), indicated more satisfying SDM (P < 0.001) and had a larger living space (P < 0.001). All patients were more satisfied when they had a good psychological state and received SDM. Especially in HD patients, TS was higher when the patient had a less autonomous personality, lower cognitive functioning, more social support, a poorer physical state and poorer socio-demographic conditions (R2 = 0.26). Psychosocial characteristics play a major role in TS in dialysis patients. Within a multivariate approach, these factors are even more important than physical or environment-related factors. In practice, focusing on SDM

An Incident Cohort Study Comparing Survival on Home Hemodialysis and Peritoneal Dialysis (Australia and New Zealand Dialysis and Transplantation Registry)

PubMed Central

Nadeau-Fredette, Annie-Claire; Hawley, Carmel M.; Pascoe, Elaine M.; Chan, Christopher T.; Clayton, Philip A.; Polkinghorne, Kevan R.; Boudville, Neil; Leblanc, Martine

2015-01-01

Background and objectives Home dialysis is often recognized as a first-choice therapy for patients initiating dialysis. However, studies comparing clinical outcomes between peritoneal dialysis and home hemodialysis have been very limited. Design, setting, participants, & measurements This Australia and New Zealand Dialysis and Transplantation Registry study assessed all Australian and New Zealand adult patients receiving home dialysis on day 90 after initiation of RRT between 2000 and 2012. The primary outcome was overall survival. The secondary outcomes were on-treatment survival, patient and technique survival, and death-censored technique survival. All results were adjusted with three prespecified models: multivariable Cox proportional hazards model (main model), propensity score quintile–stratified model, and propensity score–matched model. Results The study included 10,710 patients on incident peritoneal dialysis and 706 patients on incident home hemodialysis. Treatment with home hemodialysis was associated with better patient survival than treatment with peritoneal dialysis (5-year survival: 85% versus 44%, respectively; log-rank P<0.001). Using multivariable Cox proportional hazards analysis, home hemodialysis was associated with superior patient survival (hazard ratio for overall death, 0.47; 95% confidence interval, 0.38 to 0.59) as well as better on-treatment survival (hazard ratio for on-treatment death, 0.34; 95% confidence interval, 0.26 to 0.45), composite patient and technique survival (hazard ratio for death or technique failure, 0.34; 95% confidence interval, 0.29 to 0.40), and death-censored technique survival (hazard ratio for technique failure, 0.34; 95% confidence interval, 0.28 to 0.41). Similar results were obtained with the propensity score models as well as sensitivity analyses using competing risks models and different definitions for technique failure and lag period after modality switch, during which events were attributed to the

Personality and patient adherence: correlates of the five-factor model in renal dialysis.

PubMed

Christensen, A J; Smith, T W

1995-06-01

The five-factor taxonomy of personality traits has received increasing attention in the literature regarding personality correlates of health outcomes and behaviors. We examined the association of the five NEO Five-Factor Inventory dimensions to medical regimen adherence in a sample of 72 renal dialysis patients. Results indicated that Conscientiousness (Dimension III) is a five-factor trait significantly associated with adherence to the medication regimen. No other NEO-FFI dimension was significantly associated with patient adherence.

[The impact of glucose absorbed from dialysis solution on body weight gain in peritoneal dialysis treated patients].

PubMed

Jakić, Marko; Stipanić, Sanja; Mihaljević, Dubravka; Zibar, Lada; Lovcić, Vesna; Klarić, Dragan; Jakić, Marijana

2005-01-01

A proportion of peritoneal dialysis (PD) patients experience substantial body weight (BW) gain with time. It is caused by fat tissue accumulation or fluid retention. It is believed that fat tissue accumulates due to caloric contribution of glucose absorbed from dialysis solution or to the mitochondrial fat regulatory uncoupling protein (UCP) gene polymorphism. This study examined BW fluctuations in 40 patients (24 females, 16 males), treated by PD at least 36 months (initial mean age 54.50+/-9.00 years, mean BW 68.00+/-8.50 kg and mean height 164.00+/-8.50 cm), relation of the BW fluctuation and caloric contribution of glucose absorbed from dialysis solution and characteristics of the patients with BW gain. Initial BW increased after 6, 12, 24 and 36 months by 5.90+/-3.50 kg, 7.90+/-4.90 kg, 9.50+/-5.00 and 11.00+/-5.00 kg, or for 8.68, 11.62, 13.97 and 16.18% of the initial value, respectively. After the first 6 and 12 months 38 patients gained weight, 39 after 24 and all 40 patients after 36 months. There was not significant correlation between BW gain and caloric contribution of glucose absorbed from dialysis solution. Female patients had initially lower BW, but for the first 12 months period significantly increased BW more than males, and not for the other observed periods. High transporters (patients with higher transport, higher transmission of glucose from peritoneal solution into the blood, and urea and creatinine in the opposite direction, with rapid decrement of osmolality gradient between dialysate and blood that is necessary for excessive fluid elimination), had lower initial BW and, although without statistical significance, only within the first period increased BW more than low transporters. In conclusion, with time BW gain was found in all the PD dialysis patients, it was not related to caloric contribution of glucose absorbed from dialysis solution, and women and high transporters increased BW weight more than men and low transporters in the first

Measuring patient experience in dialysis: a new paradigm of quality assessment.

PubMed

Rhee, Connie M; Brunelli, Steven M; Subramanian, Lalita; Tentori, Francesca

2018-04-01

Patients' experience of care (PEC) is as an important dimension in quality of care. As a distinct entity from patient satisfaction and patient health-related quality of life, PEC is defined as patients' perceptions of the range of interactions they have with the health care system, including care from providers, facilities, and health plans. While traditionally PEC may be ascertained via informal assessments, in recent years, especially in the United States, there has been a shift towards standardized surveillance of PEC amongst dialysis patients in order to: (1) set a normative expectation regarding the importance of PEC; (2) standardize the components of patients' experience that are assessed to minimize potential "blind spots"; (3) provide a direct "voice" to the patient in communicating perceptions of their care; (4) facilitate comparisons of quality across facilities; and (5) broaden accountability for PEC to the entire multidisciplinary dialysis care team. In this review, we will discuss the significance of PEC as a quality of care metric in dialysis patients; the history of PEC assessment across other health care arenas; the development of the In-Center Hemodialysis Consumer Assessment of Healthcare Provider and Systems survey as a means to standardize PEC assessment among US dialysis patients; experiences in PEC assessment across international dialysis populations; and future areas of research needed to refine the ascertainment of PEC and its impact upon patient outcomes.

Effects of disinfectants in renal dialysis patients.

PubMed Central

Klein, E

1986-01-01

Patients receiving hemodialysis therapy risk exposure to both disinfectants and sterilants. Dialysis equipment is disinfected periodically with strong solutions of hypochlorite or formaldehyde. More recently, reuse of dialyzers has introduced the use of additional sterilants, such as hydrogen peroxide and peracetic acid. The use of these sterilants is recognized by the center staffs and the home patient as a potential risk, and residue tests are carried out for the presence of these sterilants at the ppm level. Gross hemolysis resulting from accidental hypochlorite infusion has led to cardiac arrest, probably as a result of hyperkalemia. Formaldehyde is commonly used in 4% solutions to sterilize the fluid paths of dialysis controllers and to sterilize dialyzers before reuse. It can react with red cell antigenic surfaces leading to the formation of anti-N antibodies. Such reactions probably do not occur with hypochlorite or chloramines. The major exposure risk is the low concentration of disinfectant found in municipal water used to prepare 450 L dialysate weekly. With thrice-weekly treatment schedules, the quality requirements for water used to make this solution must be met rigorously. Standards for water used in the preparation of dialysate have recently been proposed but not all patients are treated with dialysate meeting such standards. The introduction of sterilants via tap water is insidious and has led to more pervasive consequences. Both chlorine and chloramines, at concentrations found in potable water, are strong oxidants that cause extensive protein denaturation and hemolysis. Oxidation of the Fe2+ in hemoglobin to Fe3+ forms methemoglobin, which is incapable of carrying either O2 or CO2.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:3816735

A Chinese patient with peritoneal dialysis-related peritonitis caused by Gordonia terrae: a case report.

PubMed

Hou, Chenrui; Yang, Yun; Li, Ziyang

2017-02-28

Gordonia terrae is a rare cause of clinical infections, with only 23 reported cases. We report the first case of peritoneal dialysis-related peritonitis caused by Gordonia terrae in mainland China. A 52-year-old man developed peritoneal dialysis-related peritonitis and received preliminary antibiotic treatment. After claiming that his symptoms had been resolved, the patient insisted on being discharged (despite our recommendations) and did not receive continued treatment after leaving the hospital. A telephone follow-up with the patient's relatives revealed that the patient died 3 months later. Routine testing did not identify the bacterial strain responsible for the infection, although matrix-assisted laser desorption/ionization time-of-flight mass spectrometry identified the strain as Gordonia rubropertincta. However, a 16S rRNA sequence analysis using an isolate from the peritoneal fluid culture revealed that the responsible strain was actually Gordonia terrae. Similar to this case, all previously reported cases have involved a delayed diagnosis and initial treatment failure, and the definitive diagnosis required a 16S rRNA sequence analysis. Changes from an inappropriate antibiotic therapy to an appropriate one have relied on microbiological testing and were performed 7-32 days after the initial treatment. The findings from our case and the previously reported cases indicate that peritoneal dialysis-related peritonitis caused by Gordonia terrae can be difficult to identify and treat. It may be especially challenging to diagnose these cases in countries with limited diagnostic resources.

Impact of facility size and profit status on intermediate outcomes in chronic dialysis patients.

PubMed

Frankenfield, D L; Sugarman, J R; Presley, R J; Helgerson, S D; Rocco, M V

2000-08-01

Little information is available regarding the influence of dialysis facility size or profit status on intermediate outcomes in chronic dialysis patients. We have combined data from the Health Care Financing Administration (HCFA) Core Indicators Project; the end-stage renal disease (ESRD) facility survey; and the HCFA On-Line Survey, Certification, and Reporting System to analyze trends in this area. For hemodialysis patients, larger facilities were more likely than smaller facilities to perform dialysis on patients who were younger than 65 years of age, black, or undergoing dialysis 2 years or more (P < 0.001). Nonprofit facilities were more likely to perform dialysis on patients with diabetes mellitus as a cause of ESRD and less likely to perform dialysis on patients with hypertension as a cause of ESRD compared with for-profit units (P < 0.05). By multivariate analysis, larger facility size was modestly associated with a greater Kt/V value and urea reduction ratio, but not with hematocrit or serum albumin values. Facility profit status was not associated with these intermediate outcomes. For peritoneal dialysis patients, there were no significant differences in patient demographics based on facility size. More patients in nonprofit units had been undergoing dialysis 2 or more years than patients in for-profit units (P < 0.05). By univariate analysis, patients in larger facilities were more likely to have an adequacy measure performed than patients from smaller facilities (P < 0.05). There were few substantial differences in intermediate outcomes in chronic dialysis patients based on facility size or profit status.

[Correlation between dialysis solution type and cardiovascular morbidity rate in patients undergoing continuous ambulatory peritoneal dialysis].

PubMed

Stanković-Popović, Verica; Maksić, Doko; Vucinić, Zarko; Lepić, Toplica; Popović, Dragan; Milicić, Biljana

2008-03-01

Peritoneal dialysis (PD) patients have an increased risk for cardiovascular diseases. The aim of the study was to evaluate the cardiovascular changes in patients undergoing chronic PD and the eventual existing differences depending on biocompatibility of dialysis solutions. After 3 +/- 2 years of starting PD, 21 PD patients on the treatment with bioincompatible dialysis solutions (conventional glucose- based solutions: PDP-1), average age 47.43 +/- 12.87 years, and 21 PD patients on the treatment with biocompatible dialysis solutions (neutral solutions with lower level of glucose degradation products, lower concentration of Ca2+ and neutral pH: PDP-2), average age 68.62 +/- 13.98 years, participated in the longitudinal study. The average number of episodes of peritonitis was similar in both groups: 1 episode per 36 months of the treatment. The control group included 21 patients with preterminal phase of chronic renal failure (Glomerular Filtration Rate: 22.19 +/- 10.73 ml/min), average age 65.29 +/- 13.74 years. All the patients underwent transthoracal echocardiography (in order to detect: eject fraction (EF), left ventricular hypertrophy (LVH), and valvular calcification (VC) and B-mode ultrasonography of common carotid artery (CCA): IMT, lumen narrowing, and plaque detection. The values of EF were: in PDP-1 group 62.05 +/- 5.65%, in PDP-2 group 53.43 +/- 7.47%, and in the control group 56.71 +/- 8.12% (Bonferroni test, p = 0.001). The recorded LVH was: in PDP-1 group in 47.6% of the patients; in PDP-2 group in 61.9% of the patients; and in control the group in 52.4% (chi2 test; p = 0.639). The detected VC was: in PDP-1 in 52.4% of the patients, in PDP-2 group in 42.9% of the patients, and in the control group in 23.8% of the patients (chi2 test; p = 0.776). The IMT was: in PDP-1 group 1.26 +/- 0.54 mm, in PDP-2 group 1.23 +/- 0.32, and in the control group 1.25 +/- 0.27 mm (Bonferroni test; p = 0.981). An average lumen narrowing was: in PDP-1 group 13.78 +/- 18

Dialysis patients refusing kidney transplantation: data from the Slovenian Renal Replacement Therapy Registry.

PubMed

Buturović-Ponikvar, Jadranka; Gubenšek, Jakob; Arnol, Miha; Bren, Andrej; Kandus, Aljoša; Ponikvar, Rafael

2011-06-01

Kidney transplantation is considered the best renal replacement therapy (RRT) for patients with end-stage renal disease; nevertheless, some dialysis patients refuse to be transplanted. The aim of our registry-based, cross-sectional study was to compare kidney transplant candidates to dialysis patients refusing transplantation. Data were collected from the Slovenian Renal Replacement Therapy Registry database, as of 31 December 2008. Demographic and some RRT data were compared between the groups. There were 1448 dialysis patients, of whom 1343 were treated by hemodialysis and 105 by peritoneal dialysis (PD); 132 (9%) were on the waiting list for transplantation, 208 (14%) were preparing for enrollment (altogether 340 [23%] dialysis patients were kidney transplant candidates); 200 (13.7%) patients were reported to refuse transplantation, all ≤ 65 years of age; 345 (24%) were not enrolled due to medical contraindications, 482 (33%) due to age, and 82 (6%) due to other or unknown reasons. No significant difference was found in age, gender, or presence of diabetes between kidney transplant candidates vs. patients refusing transplantation (mean age 50.5 ± 13.9 vs. 51.3 ± 9.6 years, males 61% vs. 63%, diabetics 18% vs. 17%). The proportion of patients ≤ 65 years old who were refusing transplantation was 28% (187/661) for hemodialysis and 17% (13/79) for PD patients (P = 0.03). There is a considerable group of dialysis patients in Slovenia refusing kidney transplantation. Compared to the kidney transplant candidates, they are similar in age, gender and prevalence of diabetes. Patients treated by peritoneal dialysis refuse kidney transplantation less often than hemodialysis patients. © 2011 The Authors. Therapeutic Apheresis and Dialysis © 2011 International Society for Apheresis.

Patient and Health Care Professional Decision-Making to Commence and Withdraw from Renal Dialysis: A Systematic Review of Qualitative Research

PubMed Central

Flemming, Kate; Murtagh, Fliss E.M.; Johnson, Miriam J.

2015-01-01

Background and objective To ensure that decisions to start and stop dialysis in ESRD are shared, the factors that affect patients and health care professionals in making such decisions must be understood. This systematic review sought to explore how and why different factors mediate the choices about dialysis treatment. Design, setting, participants, & measurements MEDLINE, Embase, CINAHL, and PsychINFO were searched for qualitative studies of factors that affect patients’ or health care professionals’ decisions to commence or withdraw from dialysis. A thematic synthesis was conducted. Results Of 494 articles screened, 12 studies (conducted from 1985 to 2014) were included. These involved 206 patients (most receiving hemodialysis) and 64 health care professionals (age ranges: patients, 26–93 years; professionals, 26–61 years). For commencing dialysis, patients based their choice on "gut instinct," as well as deliberating over the effect of treatment on quality of life and survival. How individuals coped with decision-making was influential: Some tried to take control of the problem of progressive renal failure, whereas others focused on controlling their emotions. Health care professionals weighed biomedical factors and were led by an instinct to prolong life. Both patients and health care professionals described feeling powerless. With regard to dialysis withdrawal, only after prolonged periods on dialysis were the realities of life on dialysis fully appreciated and past choices questioned. By this stage, however, patients were physically dependent on treatment. As was seen with commencing dialysis, individuals coped with treatment withdrawal in a problem- or emotion-controlling way. Families struggled to differentiate between choosing versus allowing death. Health care teams avoided and queried discussions regarding dialysis withdrawal. Patients, however, missed the dialogue they experienced during predialysis education. Conclusions Decision-making in

[Psychiatric patients, dialysis, kidney transplant: case report and discussion].

PubMed

Melamed, Yuval; Klein, Osnat; Bzura, Georgina; Finkel, Boris; Bleich, Avi; Bernheim, Jack

2005-05-01

Psychiatric patients' coping capacity with various life situations is limited due to their mental illness. This difficulty is even more pronounced when dealing with severe physical conditions such as kidney failure, the need for dialysis and kidney transplant. In the past, similar to patients who suffered from additional physical conditions, patients with major psychiatric disorders, long-term psychotic illness such as schizophrenia, were not considered candidates for dialysis treatment. Although these attitudes have changed, there is still concern that psychiatric patients would find it difficult to cooperate with the long-term treatment required following kidney transplant, and that lack of careful adherence to medication regimens could lead to rejection of the implant. This article describes five mentally ill individuals who suffer from terminal kidney failure, and illustrates the dilemma associated with dialysis and kidney transplant in psychiatric patients. Close cooperation between the psychiatric staff and the nephrology team can lead to the hoped for outcomes.

Prevalence and Risk Factors of Lower Limb Amputation in Patients with End-Stage Renal Failure on Dialysis: A Systematic Review

PubMed Central

Vangaveti, Venkat N.

2016-01-01

Background. Renal dialysis has recently been recognised as a risk factor for lower limb amputation (LLA). However, exact rates and associated risk factors for the LLA are incompletely understood. Aim. Prevalence and risk factors of LLA in end-stage renal failure (ESRF) subjects on renal dialysis were investigated from the existing literature. Methods. Published data on the subject were derived from MEDLINE, PubMed, and Google Scholar search of English language literature from January 1, 1980, to July 31, 2015, using designated key words. Results. Seventy studies were identified out of which 6 full-text published studies were included in this systematic review of which 5 included patients on haemodialysis alone and one included patients on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputation in the renal failure on dialysis cohort ranged from 1.7% to 13.4%. Five out of the six studies identified diabetes as the leading risk factor for amputation in subjects with ESRF on renal dialysis. Other risk factors identified were high haemoglobin A1c, elevated c-reactive protein, and low serum albumin. Conclusions. This review demonstrates high rate of LLA in ESRF patients receiving dialysis therapy. It has also identified diabetes and markers of inflammation as risk factors of amputation in ESRF subjects on dialysis. PMID:27529033

Reviewing and comparing self-concept in patients undergoing hemodialysis and peritoneal dialysis

PubMed Central

Shahgholian, Nahid; Tajdari, Setareh; Nasiri, Mahmoud

2012-01-01

Background: Chronic renal disease is a health problem in today’s world. In the end-stages of renal disease patients depend upon alternative therapies including dialysis for their survival. However, dialysis causes several stressors on physical, mental and social performance of patients. The present study aimed to review and compare the self-concept in patients undergoing hemodialysis and peritoneal dialysis. Materials and Methods: This was a case-control study including two groups of patients, undergoing hemodialysis and peritoneal dialysis, who referred to Al-Zahra and Ali Asghar Hospitals, which are affiliated to Isfahan University of Medical Sciences. These groups were compared to the control group. Data were collected through completing the form of demographic characteristics and a questionnaire, written by the researcher, pertaining to the self-concept which was collected by the samples. The data were analyzed by the Software SPSS version 18. Findings: ANOVA (analysis of variance) showed that statistically there was a significant difference between mean score of self-concept in the three physical (body-image), psychological, and social self aspects in the two groups of hemodialysis and peritoneal dialysis with the control group; however, Duncan’s post-hoc analysis showed no significant difference between mean score of self-concept in the three mentioned aspects in the two groups of hemodialysis and peritoneal dialysis. Furthermore, ANOVA (analysis of variance) showed that there was no significant difference between mean score of the spiritual aspect of the self-concept in the two groups of hemodialysis and peritoneal dialysis with the control group. Duncan’s post-hoc analysis also showed no significant difference in this aspect between the two groups of hemodialysis and peritoneal dialysis. Conclusions: Patients undergoing dialysis have many psychological disorders and the type of dialysis is not of much importance in this regard; therefore, adequate

Assessment and Management of Hypertension in Patients on Dialysis

PubMed Central

Flynn, Joseph; Pogue, Velvie; Rahman, Mahboob; Reisin, Efrain; Weir, Matthew R.

2014-01-01

Hypertension is common, difficult to diagnose, and poorly controlled among patients with ESRD. However, controversy surrounds the diagnosis and treatment of hypertension. Here, we describe the diagnosis, epidemiology, and management of hypertension in dialysis patients, and examine the data sparking debate over appropriate methods for diagnosing and treating hypertension. Furthermore, we consider the issues uniquely related to hypertension in pediatric dialysis patients. Future clinical trials designed to clarify the controversial results discussed here should lead to the implementation of diagnostic and therapeutic techniques that improve long-term cardiovascular outcomes in patients with ESRD. PMID:24700870

Perspectives on Research Participation and Facilitation Among Dialysis Patients, Clinic Personnel, and Medical Providers: A Focus Group Study.

PubMed

Flythe, Jennifer E; Narendra, Julia H; Dorough, Adeline; Oberlander, Jonathan; Ordish, Antoinette; Wilkie, Caroline; Dember, Laura M

2017-12-19

Most prospective studies involving individuals receiving maintenance dialysis have been small, and many have had poor clinical translatability. Research relevance can be enhanced through stakeholder engagement. However, little is known about dialysis clinic stakeholders' perceptions of research participation and facilitation. The objective of this study was to characterize the perspectives of dialysis clinic stakeholders (patients, clinic personnel, and medical providers) on: (1) research participation by patients and (2) research facilitation by clinic personnel and medical providers. We also sought to elucidate stakeholder preferences for research communication. Qualitative study. 7 focus groups (59 participants: 8 clinic managers, 14 nurses/patient care technicians, 8 social workers/dietitians, 11 nephrologists/advanced practice providers, and 18 patients/care partners) from 7 North Carolina dialysis clinics. Clinics and participants were purposively sampled. Focus groups were recorded and transcribed. Thematic analysis. We identified 11 themes that captured barriers to and facilitators of research participation by patients and research facilitation by clinic personnel and medical providers. We collapsed these themes into 4 categories to create an organizational framework for considering stakeholder (narrow research understanding, competing personal priorities, and low patient literacy and education levels), relationship (trust, buy-in, and altruistic motivations), research design (convenience, follow-up, and patient incentives), and dialysis clinic (professional demands, teamwork, and communication) aspects that may affect stakeholder interest in participating in or facilitating research. These themes appear to shape the degree of research readiness of a dialysis clinic environment. Participants preferred short research communications delivered in multiple formats. Potential selection bias and inclusion of English-speaking participants only. Our findings

Patients with failed renal transplant may be suitable for peritoneal dialysis.

PubMed

Duman, Soner; Aşçi, Gülay; Töz, Hüseyin; Ozkahya, Mehmet; Ertilav, Muhittin; Seziş, Meltem; Ok, Ercan

2004-01-01

It has been claimed that patients with late transplant failure returning to peritoneal dialysis have lower patient and technique survival. In this retrospective study, we aimed to clarify this issue in a large PD population. Thirty-four PD patients with a failed renal transplant (FTx) and 82 PD patients who had never received a kidney transplant (Non-Tx) or HD treatment were investigated. All fTx patients were using only steroids (5-10 mg/day) for first 3 months of peritoneal dialysis. The groups were similar regarding to age, sex, residual renal function and KT/V; none of them was diabetic. Ftx group had a higher number of peritonitis attack than Non-Tx group (2.42 +/- 0.41 v 1.61 +/- 0.15, attack per patient, p = 0.013). PET status was not different. One, 3 and 5 year patient survival calculated with the Kaplan Meier method were 93%; 93%; 93% respectively in Ftx and 97%; 89%; 82% respectively in Non-Tx patients. Technique survival was 83%; 77%; 60% in Ftx and 91%; 64%; 48% in Non-Tx patients respectively. We conclude that PD appears to be a good option for fTx patients. A previous renal transplantation does not adversely affect patient and technique survival. Although the somewhat higher infection risk is of some concern, we did not observe earlier loss of peritoneal functions (high transporter) in the post transplant patients.

Falls and fall-related injuries in older dialysis patients.

PubMed

Cook, Wendy L; Tomlinson, George; Donaldson, Meghan; Markowitz, Samuel N; Naglie, Gary; Sobolev, Boris; Jassal, Sarbjit V

2006-11-01

Dialysis patients are increasingly older and more disabled. In community-dwelling seniors without kidney disease, falls commonly predict hospitalization, the onset of frailty, and the need for institutional care. Effective fall prevention strategies are available. On the basis of retrospective data, it was hypothesized that the fall rates of older (> or =65 yr) chronic outpatient hemodialysis (HD) patients would be higher than published rates for community-dwelling seniors (0.6 to 0.8 falls/patient-year). It also was hypothesized that risk factors for falls in dialysis outpatients would include polypharmacy, dialysis-related hypotension, cognitive impairment, and decreased functional status. Using a prospective cohort study design, HD patients who were > or =65 yr of age at a large academic dialysis unit were recruited. All study participants underwent baseline screening for fall risk factors. Patients were followed prospectively for a minimum of 1 yr. Falls were identified through biweekly patient interviews in the HD unit. A total of 162 patients (mean age 74.7 yr) were recruited; 57% were male. A total of 305 falls occurred in 76 (47%) patients over 190.5 person-years of follow-up (fall-incidence 1.60 falls/person-year). Injuries occurred in 19% of falls; 41 patients had multiple falls. Associated risk factors included age, comorbidity, mean predialysis systolic BP, and a history of falls. In the HD population, the fall risk is higher than in the general community, and fall-related morbidity is high. Better identification of HD patients who are at risk for falls and targeted fall intervention strategies are required.

The Green Dialysis Survey: Establishing a Baseline for Environmental Sustainability across Dialysis Facilities in Victoria, Australia.

PubMed

Barraclough, Katherine A; Gleeson, Alice; Holt, Stephen G; Agar, John Wm

2017-11-02

The Green Dialysis Survey aimed to 1) establish a baseline for environmental sustainability (ES) across Victorian dialysis facilities, and 2) guide future initiatives to reduce the environmental impact of dialysis delivery. Nurse unit managers of all Victorian public dialysis facilities received an online link to the survey, which asked 107 questions relevant to the ES of dialysis services. Responses were received from 71/83 dialysis facilities in Victoria (86%), representing 628/660 dialysis chairs (95%). Low energy lighting was present in 13 facilities (18%), 18 (25%) recycled reverse osmosis water and 7 (10%) reported use of renewable energy. Fifty-six facilities (79%) performed comingled recycling but only 27 (38%) recycled polyvinyl chloride plastic. A minority educated staff in appropriate waste management (n=30;42%) or formally audited waste generation and segregation (n=19;27%). Forty-four (62%) provided secure bicycle parking but only 33 (46%) provided shower and changing facilities. There was limited use of tele- or video-conferencing to replace staff meetings (n=19;27%) or patient clinic visits (n=13;18%). A minority considered ES in procurement decisions (n=28;39%) and there was minimal preparedness to cope with climate change. Only 39 services (49%) confirmed an ES policy and few had ever formed a green group (n=14; 20%) or were currently undertaking a green project (n=8;11%). Only 15 facilities (21%) made formal efforts to raise awareness of ES. This survey provides a baseline for practices that potentially impact the environmental sustainability of dialysis units in Victoria, Australia. It also identifies achievable targets for attention. This article is protected by copyright. All rights reserved.

Uremic Pruritus, Dialysis Adequacy, and Metabolic Profiles in Hemodialysis Patients: A Prospective 5-Year Cohort Study

PubMed Central

Chen, Hung-Yuan; Chiu, Yen-Ling; Hsu, Shih-Ping; Pai, Mei-Fen; Ju-YehYang; Lai, Chun-Fu; Lu, Hui-Min; Huang, Shu-Chen; Yang, Shao-Yu; Wen, Su-Yin; Chiu, Hsien-Ching; Hu, Fu-Chang; Peng, Yu-Sen; Jee, Shiou-Hwa

2013-01-01

Background Uremic pruritus is a common and intractable symptom in patients on chronic hemodialysis, but factors associated with the severity of pruritus remain unclear. This study aimed to explore the associations of metabolic factors and dialysis adequacy with the aggravation of pruritus. Methods We conducted a 5-year prospective cohort study on patients with maintenance hemodialysis. A visual analogue scale (VAS) was used to assess the intensity of pruritus. Patient demographic and clinical characteristics, laboratory parameters, dialysis adequacy (assessed by Kt/V), and pruritus intensity were recorded at baseline and follow-up. Change score analysis of the difference score of VAS between baseline and follow-up was performed using multiple linear regression models. The optimal threshold of Kt/V, which is associated with the aggravation of uremic pruritus, was determined by generalized additive models and receiver operating characteristic analysis. Results A total of 111 patients completed the study. Linear regression analysis showed that lower Kt/V and use of low-flux dialyzer were significantly associated with the aggravation of pruritus after adjusting for the baseline pruritus intensity and a variety of confounding factors. The optimal threshold value of Kt/V for pruritus was 1.5 suggested by both generalized additive models and receiver operating characteristic analysis. Conclusions Hemodialysis with the target of Kt/V ≥1.5 and use of high-flux dialyzer may reduce the intensity of pruritus in patients on chronic hemodialysis. Further clinical trials are required to determine the optimal dialysis dose and regimen for uremic pruritus. PMID:23940749

Measures of blood pressure and cognition in dialysis patients

USDA-ARS?s Scientific Manuscript database

There are few reports on the relationship of blood pressure with cognitive function in maintenance dialysis patients. The Cognition and Dialysis Study is an ongoing investigation of cognitive function and its risk factors in six Boston area hemodialysis units. In this analysis, we evaluated the rela...

Accuracy of dialysis medical records in determining patients' interest in and suitability for transplantation.

PubMed

Huml, Anne M; Sullivan, Catherine M; Pencak, Julie A; Sehgal, Ashwini R

2013-01-01

We sought to determine the accuracy of dialysis medical records in identifying patients' interest in and suitability for transplantation. Cluster randomized controlled trial. A total of 167 patients recruited from 23 hemodialysis facilities. Navigators met with intervention patients to provide transplant information and assistance. Control patients continued to receive usual care. Agreement at study initiation between medical records and (i) patient self-reported interest in transplantation and (ii) study assessments of medical suitability for transplant referral. Medical record assessments, self-reports, and study assessments of patient's interest in and suitability for transplantation. There was disagreement between medical records and patient self-reported interest in transplantation for 66 (40%) of the 167 study patients. In most of these cases, patients reported being more interested in transplantation than their medical records indicated. The study team determined that all 92 intervention patients were medically suitable for transplant referral. However, for 38 (41%) intervention patients, medical records indicated that they were not suitable. About two-thirds of these patients successfully moved forward in the transplant process. Dialysis medical records are frequently inaccurate in determining patient's interest in and suitability for transplantation. © 2013 John Wiley & Sons A/S.

Evaluation of adherence and depression among patients on peritoneal dialysis.

PubMed

Yu, Zhen Li; Yeoh, Lee Ying; Seow, Ying Ying; Luo, Xue Chun; Griva, Konstadina

2012-07-01

It is challenging for dialysis patients to maintain adherence to their medical regimen, and symptoms of depression are prevalent among them. Limited data is available about adherence and depression among patients receiving peritoneal dialysis (PD). This study aimed to examine the rates of treatment non-adherence and depression in PD patients. A total of 20 PD patients (response rate 71.4%; mean age 64.4 ± 11.6 years) were assessed using the Beliefs about Medicines Questionnaire, Self Efficacy for Managing Chronic Disease Scale, Hospital Anxiety and Depression Scale (HAD) and Kidney Disease Quality of Life-Short Form. A self-reported adherence (PD exchanges, medication and diet) scale developed for the study was also included. Medical information (e.g. most recent biochemistry results) was obtained from chart review. The mean self-reported scores indicated an overall high level of adherence, although a significant proportion of patients were non-adherent. Among the latter, 20% of patients were non-adherent to medication and 26% to diet due to forgetfulness, while 15% and 26% of patients admitted to deliberate non-adherence to medication and diet, respectively. Treatment modality, employment, self-care status and self-efficacy were associated with overall adherence. Using a cutoff point of 8 for HAD depression and anxiety subscales, 40% of patients were found to be depressed and 30% had symptoms of anxiety. This is the first study to document treatment adherence and depression among PD patients in Singapore. Findings of high prevalence of depression and anxiety, and reports of poor adherence warrant development of intervention programmes.

Should ribavirin be used to treat hepatitis C in dialysis patients?

PubMed

Carrion, Andres F; Fabrizi, Fabrizio; Martin, Paul

2011-01-01

Hepatitis C virus infection adversely affects outcomes in patients with chronic kidney disease undergoing maintenance dialysis. Pegylated interferon and ribavirin, the standard-of-care treatment in patients with intact renal function, is associated with severe side effects, toxicity, and high dropout rates in this population. Ribavirin has an important role in maintaining antiviral response following completion of therapy and increases sustained viral response (SVR) rates. However, the use of ribavirin in dialysis patients has been limited by the high frequency of severe hemolytic anemia and is currently reserved for study protocols and highly selected candidates treated at experienced centers. Encouraging data from small trials have shown a significant increase in SVR rates with the use of different dosing regimens of ribavirin in addition to interferon-based therapy and aggressive erythroid-stimulating agent support in dialysis patients. Use of ribavirin in selected dialysis patients, particularly renal transplant candidates, by experienced clinicians is appropriate. © 2011 Wiley Periodicals, Inc.

Effects of disinfectants in renal dialysis patients

DOE Office of Scientific and Technical Information (OSTI.GOV)

Klein, E.

1986-11-01

Patients receiving hemodialysis therapy risk exposure to both disinfectants and sterilants. Dialysis equipment is disinfected periodically with strong solutions of hypochlorite or formaldehyde. Gross hemolysis resulting from accidental hypochlorite infusion has led to cardiac arrest, probably as a result of hyperkalemia. Formaldehyde is commonly used in 4% solutions to sterilize the fluid paths of dialysis controllers and to sterilize dialyzers before reuse. It can react with red cell antigenic surfaces leading to the formation of anti-N antibodies. The major exposure risk is the low concentration of disinfectant found in municipal water used to prepare 450 L dialysate weekly. With thrice-weeklymore » treatment schedules, the quality requirements for water used to make this solution must be met rigorously. Standards for water used in the preparation of dialysate have recently been proposed but not all patients are treated with dialysate meeting such standards. The introduction of sterilants via tap water is insidious and has let to more pervasive consequences. Both chlorine and chloramines, at concentrations found in potable water, are strong oxidants that cause extensive protein denaturation and hemolysis. Oxidation of the Fe/sup 2 +/ in hemoglobin to Fe/sup 3 +/ forms methemoglobin, which is incapable of carrying either O/sub 2/ or CO/sub 2/. Chloramine can form not only methemoglobin, but can also denature proteins within the red cell, thus forming aggregates (Heinz bodies). Chloramines also inhibit hexose monophosphate shunt activity, a mechanism that makes the red cell even more susceptible to oxidant damage.« less

Australian consumer perspectives on dialysis: first national census.

PubMed

Ludlow, Marie J; Lauder, Lydia A; Mathew, Timothy H; Hawley, Carmel M; Fortnum, Debbie

2012-11-01

The percentage of people in Australia who undertake home dialysis has steadily decreased over the past 40 years and varies within Australia. Consumer factors related to this decline have not previously been determined. A 78-question survey was developed and piloted in 2008 and 2009. Survey forms were distributed to all adult routine dialysis patients in all Australian states and territories (except Northern Territory) between 2009 and 2010. Of 9223 distributed surveys, 3250 were completed and returned. 49% of respondents indicated they had no choice in the type of dialysis and 48% had no choice in dialysis location. Respondents were twice as likely to receive information about haemodialysis (85%) than APD (39%) or CAPD (41%). The provision of education regarding home modalities differed significantly between states, and decreased with increasing patient age. Additional nursing support and reimbursement of expenses increased the proportion of those willing to commence dialysis at home, from 13% to 34%. State differences in the willingness to consider home dialysis, the degree of choice in dialysis location, the desire to change current dialysis type and/or location, and the provision of information about dialysis were identified. The delivery of pre-dialysis education is variable, and does not support all options of dialysis for all individuals. State variances indicate that local policy and health professional teams significantly influence the operation of dialysis programs. © 2012 The Authors. Nephrology © 2012 Asian Pacific Society of Nephrology.

Low-dose dialysis combined with low protein intake can maintain nitrogen balance in peritoneal dialysis patients in poor economies
.

PubMed

Su, Chun-Yan; Wang, Tao; Lu, Xin-Hong; Ma, Sha; Tang, Wen; Wang, Pei-Yu

2017-02-01

Due to limited economic conditions, we tried to provide "fitted" dialysis doses instead of the doses recommended by the international guidelines to the individual patients. In the present cross-sectional study, we studied the dialysis adequacy and nutritional status of 5 peritoneal dialysis patients who had a low dialysis dose (2 bags, 4,000 mL/day). The 3-day dietary records were reviewed to calculate patients' energy, protein, and nitrogen intake (NI). The nitrogen removal (NR) from urine and dialysate was measured by Kjeldahl technique. Fecal nitrogen was estimated as 0.0155 g/kg/day. Subjective global nutritional assessment was used to evaluate the nutritional status. Among the 5 patients, 1 male and 4 female, mean age was 59 (42 - 81) years, dialysis duration 43 (33 - 74) months, body weight 51.05 ± 2.53 kg. The mean dietary protein intake was 0.66 g/kg/day, total weekly Kt/v was 1.25 (residual kidney Kt/v was 0.09), and total daily fluid removal was 699 mL. However, they achieved lower-level neutral nitrogen balance (NI 5.26 ± 0.93 g/day vs. NR 5.33 ± 0.81 g/day, N balance -0.07 ± 0.60 g/day). All of them maintained good nutritional status (SGA "A") without symptoms of nitrogen retention (serum urea 22 ± 4.18 mmol/L). Lower dialysis dose with lower daily protein intake can achieve a lower-level nitrogen balance and does not lead to malnutrition. It may be an effective approach to solve the dialysis problem for the economically week population in China, especially for people with a smaller body size with lower transport membrane.
.

Symptom Management of the Patient with CKD: The Role of Dialysis

PubMed Central

Cabrera, Valerie Jorge; Hansson, Joni; Kliger, Alan S.

2017-01-01

As kidney disease progresses, patients often experience a variety of symptoms. A challenge for the nephrologist is to help determine if these symptoms are related to advancing CKD or the effect of various comorbidities and/or medications prescribed. The clinician also must decide the timing of dialysis initiation. The initiation of dialysis can have a variable effect on quality of life measures and the alleviation of uremic signs and symptoms, such as anorexia, fatigue, cognitive impairment, depressive symptoms, pruritus, and sleep disturbances. Thus, the initiation of dialysis should be a shared decision–making process among the patient, the family and the nephrology team; information should be provided, in an ongoing dialogue, to patients and their families concerning the benefits, risks, and effect of dialysis therapies on their lives. PMID:28148557

Hypomagnesemia Is Associated with Increased Mortality among Peritoneal Dialysis Patients.

PubMed

Cai, Kedan; Luo, Qun; Dai, Zhiwei; Zhu, Beixia; Fei, Jinping; Xue, Congping; Wu, Dan

2016-01-01

Hypomagnesemia has been associated with an increase in mortality among the general population as well as patients with chronic kidney disease or those on hemodialysis. However, this association has not been thoroughly studied in patients undergoing peritoneal dialysis. The aim of this study was to evaluate the association between serum magnesium concentrations and all-cause and cardiovascular mortalities in peritoneal dialysis patients. This single-center retrospective study included 253 incident peritoneal dialysis patients enrolled between July 1, 2005 and December 31, 2014 and followed to June 30, 2015. Patient's demographic characteristics as well as clinical and laboratory measurements were collected. Of 253 patients evaluated, 36 patients (14.2%) suffered from hypomagnesemia. During a median follow-up of 29 months (range: 4-120 months), 60 patients (23.7%) died, and 35 (58.3%) of these deaths were attributed to cardiovascular causes. Low serum magnesium was positively associated with peritoneal dialysis duration (r = 0.303, p < 0.001) as well as serum concentrations of albumin (r = 0.220, p < 0.001), triglycerides (r = 0.160, p = 0.011), potassium (r = 0.156, p = 0.013), calcium(r = 0.299, p < 0.001)and phosphate (r = 0.191, p = 0.002). Patients in the hypomagnesemia group had a lower survival rate than those in the normal magnesium groups (p < 0.001). In a multivariate Cox proportional hazards regression analysis, serum magnesium was an independent negative predictor of all-cause mortality (hazard ratio [HR] = 0.075, p = 0.011) and cardiovascular mortality (HR = 0.003, p < 0.001), especially in female patients. However, in univariate and multivariate Cox analysis, △Mg(difference between 1-year magnesium and baseline magnesium) was not an independent predictor of all-cause mortality and cardiovascular mortality. Hypomagnesemia was common among peritoneal dialysis patients and was independently associated with all-cause mortality and cardiovascular mortality.

TEMPORAL TRENDS AND FACTORS ASSOCIATED WITH MEDICATION PRESCRIPTION PATTERNS IN PERITONEAL DIALYSIS PATIENTS.

PubMed

Campos, Ludimila G; Bragg-Gresham, Jennifer; Han, Yun; Moraes, Thyago P; Figueiredo, Ana E; Barretti, Pasqual; Balkrishnan, Rajesh; Saran, Rajiv; Pecoits-Filho, Roberto

2018-06-06

Patients on peritoneal dialysis (PD) suffer from a high burden of comorbidities, which are managed with multiple medications. Determinants of prescription patterns are largely unknown in this population. This study assesses temporal changes and factors associated with medication prescription in a nationally representative population of patients on PD under the universal coverage healthcare system in Brazil. Incident patients recruited in the Brazilian Peritoneal Dialysis Study (BRAZPD) from December 2004 to January 2011, stratified by prior hemodialysis (HD) treatment, were included in the analysis. Multivariable logistic regression was used to assess the association between medication prescription and socioeconomic factors. Yearly prevalent cross-sections were calculated to estimate prescription over time. Medication prescription was in general higher among patients who had previously received HD, compared with those who started renal replacement therapy (RRT) directly on PD. Prescription increased from baseline to 6 months of PD therapy, particularly in those who did not previously receive HD. After accounting for patient characteristics, significant associations were found between socioeconomic factors, geographic region, and medication prescription patterns. Finally, the prescription of all cardioprotective and anemia medications and phosphate binders increased significantly over time. In a PD population under universal coverage in a developing country, there was an increase in drug prescription during the first 6 months on PD, and a trend toward more liberal prescription of medications in later years. Independent from patient characteristics and comorbidities, socioeconomic factors influenced drug prescriptions that likely impact patient outcome, calling for public health action to decrease potential inequities in management of comorbidities in PD patients.

[Refusal of initiation of dialysis by elderly patients with chronic renal failure].

PubMed

Fujimaki, Hiroshi; Kasuya, Yutaka; Kawaguchi, Sachiko; Hara, Shino; Koga, Shiro; Takahashi, Tadao; Mizuno, Shoichi

2005-07-01

Refusal of dialysis is not uncommon in elderly patients with chronic renal failure. In this study, we retrospectively inspected our dealings with patients who refused our offer to initiate dialysis. In addition, we discussed how to grasp the meaning of this phenomenon. We treated 152 patients with advanced chronic renal failure aged 60 years and over at Tokyo Metropolitan Geriatric Hospital. The patients fulfilling the following two criteria were considered to be refusal cases. The first criterion was that an acceptance of the initiation of dialysis could not be obtained in spite of repeated counseling. The second criterion was that a definite outcome was precipitated by the development of severe uremic symptoms. In every refusal case, clinical characteristics and household members were surveyed. Verbal expressions of the reasons for refusal were retrieved from medical charts. The outcome was also studied. The two criteria were fulfilled in 7 cases. The male/female ratio was 5:2. The age was 78 +/- 7 years (mean +/- standard deviation). All but one cases were ambulatory, and all cases had normal cognitive function. Four cases were married, and the other cases had lost their partners. The number of household members was 3.9 +/- 1.8. We speculated that every case could maintain a good quality of life even after the initiation of dialysis. Representative expressions of the reasons for refusal were "I have already lived fully" and "I would prefer to accept death rather than dialysis". The outcome was urgent initiation of dialysis (five cases) and death (two cases). The time between initial counseling and the outcome was 115 +/- 37 days. Accepting or refusing dialysis therapy is a selection related to life or death. We must make an effort to obtain consent to initiating dialysis if patients are assessed as suitable for dialysis.

Hemodialysis patients receiving a greater Kt dose than recommended have reduced mortality and hospitalization risk.

PubMed

Maduell, Francisco; Ramos, Rosa; Varas, Javier; Martin-Malo, Alejandro; Molina, Manuel; Pérez-Garcia, Rafael; Marcelli, Daniele; Moreso, Francesc; Aljama, Pedro; Merello, Jose Ignacio

2016-12-01

Achieving an adequate dialysis dose is one of the key goals for dialysis treatments. Here we assessed whether patients receiving the current cleared plasma volume (Kt), individualized for body surface area per recommendations, had improved survival and reduced hospitalizations at 2 years of follow-up. Additionally, we assessed whether patients receiving a greater dose gained more benefit. This prospective, observational, multicenter study included 6129 patients in 65 Fresenius Medical Care Spanish facilities. Patients were classified monthly into 1 of 10 risk groups based on the difference between achieved and target Kt. Patient groups with a more negative relationship were significantly older with a higher percentage of diabetes mellitus and catheter access. Treatment dialysis time, effective blood flow, and percentage of on-line hemodiafiltration were significantly higher in groups with a higher dose. The mortality risk profile showed a progressive increase when achieved minus target Kt became more negative but was significantly lower in the group with 1 to 3 L clearance above target Kt and in groups with greater increases above target Kt. Additionally, hospitalization risk appeared significantly reduced in groups receiving 9 L or more above the minimum target. Thus, prescribing an additional 3 L or more above the minimum Kt dose could potentially reduce mortality risk, and 9 L or more reduce hospitalization risk. As such, future prospective studies are required to confirm these dose effect findings. Copyright © 2016 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.

Oral nutritional supplementation in patients undergoing peritoneal dialysis: a randomised, crossover pilot study.

PubMed

Salamon, Karen M; Lambert, Kelly

2018-06-01

Malnutrition is a significant problem in those undergoing peritoneal dialysis (PD). Factors such as gastrointestinal (GI) symptoms and the need for a fluid reduced diet can limit tolerance and thereby the efficacy of oral nutritional supplements to treat malnutrition. To evaluate the acceptability and impact of two different forms of oral nutrition supplementation for 16 weeks on nutritional markers and quality of life of malnourished patients undergoing PD. A randomised, within-subject cross-over study. Patients assessed as malnourished or with serum albumin <35 g/l were recruited. Participants were randomised to receive either 200 ml of a 1.25 kcal/ml nutrition supplement or a high protein nutrition supplement bar, for eight weeks. Each group then crossed over to receive the alternative supplement for eight weeks. Total intervention time was 16 weeks. Serum albumin, serum transthyretin and food intake were evaluated at baseline, at 8 and 16 weeks. Subjective Global Assessment, the presence of GI symptoms and quality of life were evaluated at baseline and 16 weeks. Sixteen weeks of nutritional support was associated with statistically significant improvements in weight and a reduction in the proportion of patients who were malnourished. There was no difference in the impact of bars compared with liquid oral nutrition supplementation. Patients preferred the fluid supplement to the bars. Sixteen weeks of nutritional support improved nutritional status in malnourished patients on PD. © 2017 European Dialysis and Transplant Nurses Association/European Renal Care Association.

Natural disasters and dialysis care in the Asia-Pacific.

PubMed

Gray, Nicholas A; Wolley, Martin; Liew, Adrian; Nakayama, Masaaki

2015-12-01

The impact of natural disasters on the provision of dialysis services has received increased attention in the last decade following Hurricane Katrina devastating New Orleans in 2005. The Asia-Pacific is particularly vulnerable to earthquakes, tsunami, typhoons (also known as cyclones and hurricanes) or storms and flooding. These events can seriously interrupt provision of haemodialysis with adverse effects for patients including missed dialysis, increased hospitalization and post-traumatic stress disorder. Furthermore, haemodialysis patients may need to relocate and experience prolonged periods of displacement from family and social supports. In contrast to haemodialysis, most literature suggests peritoneal dialysis in a disaster situation is more easily managed and supported. It has become apparent that dialysis units and patients should be prepared for a disaster event and that appropriate planning will result in reduced confusion and adverse outcomes should a disaster occur. Numerous resources are now available to guide dialysis units, patients and staff in preparation for a possible disaster. This article will examine the disaster experiences of dialysis units in the Asia-Pacific, the impact on patients and staff, methods employed to manage during the disaster and suggested plans for reducing the impact of future disasters. © 2015 Asian Pacific Society of Nephrology.

Phosphate-containing dialysis solution prevents hypophosphatemia during continuous renal replacement therapy

PubMed Central

BROMAN, M; CARLSSON, O; FRIBERG, H; WIESLANDER, A; GODALY, G

2011-01-01

Background Hypophosphatemia occurs in up to 80% of the patients during continuous renal replacement therapy (CRRT). Phosphate supplementation is time-consuming and the phosphate level might be dangerously low before normophosphatemia is re-established. This study evaluated the possibility to prevent hypophosphatemia during CRRT treatment by using a new commercially available phosphate-containing dialysis fluid. Methods Forty-two heterogeneous intensive care unit patients, admitted between January 2007 and July 2008, undergoing hemodiafiltration, were treated with a new Gambro dialysis solution with 1.2 mM phosphate (Phoxilium) or with standard medical treatment (Hemosol B0). The patients were divided into three groups: group 1 (n=14) receiving standard medical treatment and intravenous phosphate supplementation as required, group 2 (n=14) receiving the phosphate solution as dialysate solution and Hemosol B0 as replacement solution and group 3 (n=14) receiving the phosphate-containing solution as both dialysate and replacement solutions. Results Standard medical treatment resulted in hypophosphatemia in 11 of 14 of the patients (group 1) compared with five of 14 in the patients receiving phosphate solution as the dialysate solution and Hemosol B0 as the replacement solution (group 2). Patients treated with the phosphate-containing dialysis solution (group 3) experienced stable serum phosphate levels throughout the study. Potassium, ionized calcium, magnesium, pH, pCO2 and bicarbonate remained unchanged throughout the study. Conclusion The new phosphate-containing replacement and dialysis solution reduces the variability of serum phosphate levels during CRRT and eliminates the incidence of hypophosphatemia. PMID:21039362

Quality of Life and Physical Function in Older Patients on Dialysis: A Comparison of Assisted Peritoneal Dialysis with Hemodialysis

PubMed Central

Iyasere, Osasuyi U.; Johansson, Lina; Huson, Les; Smee, Joanna; Maxwell, Alexander P.; Farrington, Ken; Davenport, Andrew

2016-01-01

Background and objectives In-center hemodialysis (HD) is often the default dialysis modality for older patients. Few centers use assisted peritoneal dialysis (PD), which enables treatment at home. This observational study compared quality of life (QoL) and physical function between older patients on assisted PD and HD. Design, setting, participants, & measurements Patients on assisted PD who were >60 years old and on dialysis for >3 months were recruited and matched to patients on HD (needing hospital transport) by age, sex, diabetes, dialysis vintage, ethnicity, and index of deprivation. Frailty was assessed using the Clinical Frailty Scale. QoL assessments included Hospital Anxiety and Depression Scale (HADS), Short Form-12, Palliative Outcomes Symptom Scale (renal), Illness Intrusiveness Rating Scale, and Renal Treatment Satisfaction Questionnaire (RTSQ). Physical function was evaluated by Barthel Score and timed up and go test. Results In total, 251 patients (129 PD and 122 HD) were recruited. In unadjusted analysis, patients on assisted PD had a higher prevalence of possible depression (HADS>8; PD=38.8%; HD=23.8%; P=0.05) and higher HADS depression score (median: PD=6; HD=5; P=0.05) but higher RTSQ scores (median: PD=55; HD=51; P<0.01). In a generalized linear regression model adjusting for age, sex, comorbidity, dialysis vintage, and frailty, assisted PD continued to be associated with higher RTSQ scores (P=0.04) but not with other QoL measures. Conclusions There are no differences in measures of QoL and physical function between older patients on assisted PD and comparable patients on HD, except for treatment satisfaction, which is higher in patients on PD. Assisted PD should be considered as an alternative to HD for older patients, allowing them to make their preferred choices. PMID:26712808

Hemoglobin and 2,3-diphosphoglycerate levels in transfused dialysis patients with myocardial infarction.

PubMed

Crowley, J P; Valeri, C R; Metzger, J B; Pono, L; Chazan, J

1992-01-01

Thirty frequently transfused patients on long term hemodialysis were studied and a similar number of age and sex-matched patients who were infrequently transfused were used as a control group to ascertain the influence of a previous myocardial infarction (MI) on transfusion requirements. The frequency of previous MI on electrocardiogram (ECG) in the transfused and control groups was similar (40 percent and 37 percent, respectively). In frequently transfused dialysis patients with MI, the hemoglobin level (transfusion trigger) at which these patients were transfused was higher than that of frequently transfused patients without MI (8.3 +/- 1.5 g per dl vs. 6.9 +/- 1 g per dl, p less than 0.01) which indicated that patients without MI tolerated a greater degree of anemia than those with MI. The 2,3-diphosphoglycerate (2,3-DPG) levels were significantly elevated in all transfused patients when compared to matched controls. However, levels of 2,3-DPG were significantly higher in MI patients receiving frequent transfusions than in other transfused patients, suggesting oxygen demands may not have been fully met despite the frequent transfusions. The results suggest levels of 2,3-DPG deserve further study in relation to the adequacy of tissue oxygenation in anemic dialysis patients.

Myths in peritoneal dialysis.

PubMed

Lee, Martin B; Bargman, Joanne M

2016-11-01

To clarify misconceptions about the feasibility and risks of peritoneal dialysis that unnecessarily limit peritoneal dialysis uptake or continuation in patients for whom peritoneal dialysis is the preferred dialysis modality. The inappropriate choice of haemodialysis as a result of these misconceptions contributes to low peritoneal dialysis penetrance, increases transfer from peritoneal dialysis to haemodialysis, increases expenditure on haemodialysis and compromises quality of life for these patients. Peritoneal dialysis is an excellent renal replacement modality that is simple, cost-effective and provides comparable clinical outcomes to conventional in-centre haemodialysis. Unfortunately, many patients are deemed unsuitable to start or continue peritoneal dialysis because of false or inaccurate beliefs about peritoneal dialysis. Here, we examine some of these 'myths' and critically review the evidence for and against each of them. We review the feasibility and risk of peritoneal dialysis in patients with prior surgery, ostomies, obesity and mesh hernia repairs. We examine the fear of mediastinitis with peritoneal dialysis after coronary artery bypass graft surgery and the belief that the use of hypertonic glucose dialysate causes peritoneal membrane failure. By clarifying common myths about peritoneal dialysis, we hope to reduce overly cautious practices surrounding this therapy.

Dialysis modality preference of patients with CKD and family caregivers: a discrete-choice study.

PubMed

Morton, Rachael L; Snelling, Paul; Webster, Angela C; Rose, John; Masterson, Rosemary; Johnson, David W; Howard, Kirsten

2012-07-01

Dialysis modality preferences of patients with chronic kidney disease (CKD) and family caregivers are important, yet rarely quantified. Prospective, unlabeled, discrete-choice experiment with random-parameter logit analysis. Adults with stages 3-5 CKD and caregivers educated about dialysis treatment options from 8 Australian renal clinics. Preferences for and trade-offs between the dialysis treatment attributes of life expectancy, number of hospital visits per week, ability to travel, hours per treatment, treatment time of day, subsidized transport service, and flexibility of treatment schedule. Results presented as ORs for preferring home-based or in-center dialysis to conservative care. 105 predialysis patients and 73 family caregivers completed the study. Median patient age was 63 years, and mean estimated glomerular filtration rate was 18.1 (range, 6-34) mL/min/1.73 m(2). Median caregiver age was 61 years. Home-based dialysis (either peritoneal or home hemodialysis) was chosen by patients in 65% of choice sets; in-center dialysis, in 35%; and conservative care, in 10%. For caregivers, this was 72%, 25%, and 3%, respectively. Both patients and caregivers preferred longer rather than shorter hours of dialysis (ORs of 2.02 [95% CI, 1.51-2.70] and 2.67 [95% CI, 1.85-3.85] for patients and caregivers, respectively), but were less likely to choose nocturnal than daytime dialysis (ORs of 0.07 [95% CI, 0.01-0.75] and 0.03 [95% CI, 0.01-0.20]). Patients were willing to forgo 23 (95% CI, 19-27) months of life expectancy with home-based dialysis to decrease their travel restrictions. For caregivers, this was 17 (95% CI, 16-18) patient-months. Data were limited to stated preferences rather than actual choice of dialysis modality. Our study suggests that it is rare for caregivers to prefer conservative nondialytic care for family members with CKD. Home-based dialysis modalities that enable patients and their family members to travel with minimal restriction would be

Variability of blood pressure in dialysis patients: a new marker of cardiovascular risk.

PubMed

Di Iorio, Biagio; Di Micco, Lucia; Torraca, Serena; Sirico, Maria Luisa; Guastaferro, Pasquale; Chiuchiolo, Luigi; Nigro, Filippo; De Blasio, Antonietta; Romano, Paolo; Pota, Andrea; Rubino, Roberto; Morrone, Luigi; Lopez, Teodoro; Casino, Francesco Gaetano

2013-01-01

Hemodialysis patients have a high cardiovascular mortality, and hypertension is the most prevalent treatable risk factor. We aimed to assess the predictive significance of dialysis-to-dialysis variability in blood pressure in hemodialysis patients. We performed a historical cohort study in 1,088 prevalent hemodialysis patients, followed up for 5 years. The risk of cardiovascular death was determined in relation to dialysis-to-dialysis variability in blood pressure, maximum blood pressure and pulse pressure. Variability in blood pressure was a predictor of cardiovascular death (hazard ratio [HR] = 1.242; 95% confidence interval [95% CI], 1.004-1.537; p=0.046). Also age (HR=1.021; 95% CI, 1.011-1.048; p=0.049), diabetes (HR=1.134; 95% CI, 1.128-1.451; p=0.035), creatinine (HR=0.837; 95% CI, 0.717-0.977; p=0.024) and albumin (HR=0.901; 95% CI, 0.821-0.924; p=0.022) influenced mortality. Maximum blood pressure and pulse pressure did not show any effect on cardiovascular death. Dialysis-to-dialysis variability in blood pressure is a predictor of cardiovascular mortality in hemodialysis patients, and blood pressure variability may be used in managing hypertension and predicting outcomes in dialysis patients.

Exercise in Patients on Dialysis: A Multicenter, Randomized Clinical Trial.

PubMed

Manfredini, Fabio; Mallamaci, Francesca; D'Arrigo, Graziella; Baggetta, Rossella; Bolignano, Davide; Torino, Claudia; Lamberti, Nicola; Bertoli, Silvio; Ciurlino, Daniele; Rocca-Rey, Lisa; Barillà, Antonio; Battaglia, Yuri; Rapanà, Renato Mario; Zuccalà, Alessandro; Bonanno, Graziella; Fatuzzo, Pasquale; Rapisarda, Francesco; Rastelli, Stefania; Fabrizi, Fabrizio; Messa, Piergiorgio; De Paola, Luciano; Lombardi, Luigi; Cupisti, Adamasco; Fuiano, Giorgio; Lucisano, Gaetano; Summaria, Chiara; Felisatti, Michele; Pozzato, Enrico; Malagoni, Anna Maria; Castellino, Pietro; Aucella, Filippo; Abd ElHafeez, Samar; Provenzano, Pasquale Fabio; Tripepi, Giovanni; Catizone, Luigi; Zoccali, Carmine

2017-04-01

Previous studies have suggested the benefits of physical exercise for patients on dialysis. We conducted the Exercise Introduction to Enhance Performance in Dialysis trial, a 6-month randomized, multicenter trial to test whether a simple, personalized walking exercise program at home, managed by dialysis staff, improves functional status in adult patients on dialysis. The main study outcomes included change in physical performance at 6 months, assessed by the 6-minute walking test and the five times sit-to-stand test, and in quality of life, assessed by the Kidney Disease Quality of Life Short Form (KDQOL-SF) questionnaire. We randomized 296 patients to normal physical activity (control; n =145) or walking exercise ( n =151); 227 patients (exercise n =104; control n =123) repeated the 6-month evaluations. The distance covered during the 6-minute walking test improved in the exercise group (mean distance±SD: baseline, 328±96 m; 6 months, 367±113 m) but not in the control group (baseline, 321±107 m; 6 months, 324±116 m; P <0.001 between groups). Similarly, the five times sit-to-stand test time improved in the exercise group (mean time±SD: baseline, 20.5±6.0 seconds; 6 months, 18.2±5.7 seconds) but not in the control group (baseline, 20.9±5.8 seconds; 6 months, 20.2±6.4 seconds; P =0.001 between groups). The cognitive function score ( P =0.04) and quality of social interaction score ( P =0.01) in the kidney disease component of the KDQOL-SF improved significantly in the exercise arm compared with the control arm. Hence, a simple, personalized, home-based, low-intensity exercise program managed by dialysis staff may improve physical performance and quality of life in patients on dialysis. Copyright © 2017 by the American Society of Nephrology.

Exercise in Patients on Dialysis: A Multicenter, Randomized Clinical Trial

PubMed Central

Manfredini, Fabio; Mallamaci, Francesca; D’Arrigo, Graziella; Baggetta, Rossella; Bolignano, Davide; Torino, Claudia; Lamberti, Nicola; Bertoli, Silvio; Ciurlino, Daniele; Rocca-Rey, Lisa; Barillà, Antonio; Battaglia, Yuri; Rapanà, Renato Mario; Zuccalà, Alessandro; Bonanno, Graziella; Fatuzzo, Pasquale; Rapisarda, Francesco; Rastelli, Stefania; Fabrizi, Fabrizio; Messa, Piergiorgio; De Paola, Luciano; Lombardi, Luigi; Cupisti, Adamasco; Fuiano, Giorgio; Lucisano, Gaetano; Summaria, Chiara; Felisatti, Michele; Pozzato, Enrico; Malagoni, Anna Maria; Castellino, Pietro; Aucella, Filippo; Abd ElHafeez, Samar; Provenzano, Pasquale Fabio; Tripepi, Giovanni; Catizone, Luigi

2017-01-01

Previous studies have suggested the benefits of physical exercise for patients on dialysis. We conducted the Exercise Introduction to Enhance Performance in Dialysis trial, a 6-month randomized, multicenter trial to test whether a simple, personalized walking exercise program at home, managed by dialysis staff, improves functional status in adult patients on dialysis. The main study outcomes included change in physical performance at 6 months, assessed by the 6-minute walking test and the five times sit-to-stand test, and in quality of life, assessed by the Kidney Disease Quality of Life Short Form (KDQOL-SF) questionnaire. We randomized 296 patients to normal physical activity (control; n=145) or walking exercise (n=151); 227 patients (exercise n=104; control n=123) repeated the 6-month evaluations. The distance covered during the 6-minute walking test improved in the exercise group (mean distance±SD: baseline, 328±96 m; 6 months, 367±113 m) but not in the control group (baseline, 321±107 m; 6 months, 324±116 m; P<0.001 between groups). Similarly, the five times sit-to-stand test time improved in the exercise group (mean time±SD: baseline, 20.5±6.0 seconds; 6 months, 18.2±5.7 seconds) but not in the control group (baseline, 20.9±5.8 seconds; 6 months, 20.2±6.4 seconds; P=0.001 between groups). The cognitive function score (P=0.04) and quality of social interaction score (P=0.01) in the kidney disease component of the KDQOL-SF improved significantly in the exercise arm compared with the control arm. Hence, a simple, personalized, home-based, low-intensity exercise program managed by dialysis staff may improve physical performance and quality of life in patients on dialysis. PMID:27909047

Economic Evaluation of Urgent-Start Peritoneal Dialysis Versus Urgent-Start Hemodialysis in the United States

PubMed Central

Liu, Frank Xiaoqing; Ghaffari, Arshia; Dhatt, Harman; Kumar, Vijay; Balsera, Cristina; Wallace, Eric; Khairullah, Quresh; Lesher, Beth; Gao, Xin; Henderson, Heather; LaFleur, Paula; Delgado, Edna M.; Alvarez, Melissa M.; Hartley, Janett; McClernon, Marilyn; Walton, Surrey; Guest, Steven

2014-01-01

Abstract Patients presenting late in the course of kidney disease who require urgent initiation of dialysis have traditionally received temporary vascular catheters followed by hemodialysis. Recent changes in Medicare payment policy for dialysis in the USA incentivized the use of peritoneal dialysis (PD). Consequently, the use of more expeditious PD for late-presenting patients (urgent-start PD) has received new attention. Urgent-start PD has been shown to be safe and effective, and offers a mechanism for increasing PD utilization. However, there has been no assessment of the dialysis-related costs over the first 90 days of care. The objective of this study was to characterize the costs associated with urgent-start PD, urgent-start hemodialysis (HD), or a dual approach (urgent-start HD followed by urgent-start PD) over the first 90 days of treatment from a provider perspective. A survey of practitioners from 5 clinics known to use urgent-start PD was conducted to provide inputs for a cost model representing typical patients. Model inputs were obtained from the survey, literature review, and available cost data. Sensitivity analyses were also conducted. The estimated per patient cost over the first 90 days for urgent-start PD was $16,398. Dialysis access represented 15% of total costs, dialysis services 48%, and initial hospitalization 37%. For urgent-start HD, total per patient costs were $19,352, and dialysis access accounted for 27%, dialysis services 42%, and initial hospitalization 31%. The estimated cost for dual patients was $19,400. Urgent-start PD may offer a cost saving approach for the initiation of dialysis in eligible patients requiring an urgent-start to dialysis. PMID:25526471

Opting out of dialysis – Exploring patients' decisions to forego dialysis in favour of conservative non-dialytic management for end-stage renal disease.

PubMed

Seah, Angeline S T; Tan, Fiona; Srinivas, Subramaniam; Wu, Huei Yei; Griva, Konstadina

2015-10-01

Dialysis prolongs the life of people with end-stage renal disease (ESRD), but for patients who are elderly and suffer multiple comorbid illnesses the benefits of dialysis may be outweighed by its negative consequences. Non-dialytic conservative management has therefore become an alternative treatment route, yet little is known on patients' experience with choosing end-of-life treatment. To gain insight into the decision-making process leading to opting out of dialysis and the experience with conservative non-dialytic management from the patients' perspective. Qualitative study using semi-structured interviews. Interpretative phenomenological analysis was undertaken as the framework for data analysis. N = 9 ESRD participants who have taken the decision to forego dialysis were recruited from the advanced care programme under the National Healthcare Group, Singapore. Participants discussed life since ESRD diagnosis, and the personal and contextual factors that led them to choose conservative management. The perceived physical and financial burden of dialysis both for the individual but most importantly for their family, uncertainty over likely gains over risks which were fuelled by communication of negative dialysis stories of others, coupled with sense of life completion and achievement led them to refuse dialysis. All participants took ownership of their decision despite contrary advice by doctors and were content with their decision and current management. Study highlights the factors driving patients' decisions for conservative non-dialytic management over dialysis to allow medical professionals to offer appropriate support to patients through their decision-making process and in caring them for the rest of their lives. © 2013 John Wiley & Sons Ltd.

Symptom Management of the Patient with CKD: The Role of Dialysis.

PubMed

Cabrera, Valerie Jorge; Hansson, Joni; Kliger, Alan S; Finkelstein, Fredric O

2017-04-03

As kidney disease progresses, patients often experience a variety of symptoms. A challenge for the nephrologist is to help determine if these symptoms are related to advancing CKD or the effect of various comorbidities and/or medications prescribed. The clinician also must decide the timing of dialysis initiation. The initiation of dialysis can have a variable effect on quality of life measures and the alleviation of uremic signs and symptoms, such as anorexia, fatigue, cognitive impairment, depressive symptoms, pruritus, and sleep disturbances. Thus, the initiation of dialysis should be a shared decision-making process among the patient, the family and the nephrology team; information should be provided, in an ongoing dialogue, to patients and their families concerning the benefits, risks, and effect of dialysis therapies on their lives. Copyright © 2017 by the American Society of Nephrology.

Patient adherence and adjustment in renal dialysis: a person x treatment interactive approach.

PubMed

Christensen, A J; Smith, T W; Turner, C W; Cundick, K E

1994-12-01

We classified 52 in-center hemodialysis patients and 34 self-treated, continuous ambulatory peritoneal dialysis (CAPD) patients on two latent variable indices reflecting patient coping style (i.e., "Information Vigilance" and "Active Coping"). The concurrent and prospective interactive effects of Dialysis Type and Coping Style were examined on patient dietary and medication adherence and on patient depression. In cross-sectional analyses, higher Information Vigilance was associated with better dietary adherence for CAPD patients but poorer adherence for In-Center Hemodialysis patients. No significant effects were found on a measure of medication adherence. Information Vigilance exerted a concurrent main effect on depression, such that higher scores were associated with less depression irrespective of dialysis type. Higher Active Coping scores were associated with lower residualized change in depression for both types of dialysis.

Sociotropic or autonomous personality and problem solving in peritoneal dialysis patients.

PubMed

Demir, S; Tufan, G; Erem, O

2010-01-01

This study investigated the sociotropic and autonomous personality characteristics and perceived problem solving ability of continuous ambulatory peritoneal dialysis (CAPD) patients, and their relationship with quality of life. The study included 14 CAPD patients and 54 healthy volunteers. Sociotropy and autonomy scores were significantly higher in CAPD patients than in the healthy control group. Among CAPD patients, there was a significant correlation between problem solving and serum phosphate, parathormone levels and erythrocyte sedimentation rate. There was a negative correlation between total dialysis time and sociotropy in CAPD patients, and a positive correlation between general health/pain perception and autonomy. Appropriate medical management, time on dialysis and positive self-perception of health were correlated with better problem solving ability and higher autonomous but lower sociotropic personality styles.

Effect of the timing of dialysis initiation on left ventricular hypertrophy and ınflammation in pediatric patients.

PubMed

Bakkaloğlu, Sevcan A; Kandur, Yaşar; Serdaroğlu, Erkin; Noyan, Aytül; Bayazıt, Aysun Karabay; Sever, Lale; Özlü, Sare Gülfem; Özçelik, Gül; Dursun, İsmail; Alparslan, Caner

2017-09-01

The optimal time for dialysis initiation in adults and children with chronic kidney disease remains unclear. The aim of this study was to evaluate the impact of dialysis timing on different outcome parameters, in particular left ventricular (LV) morphology and inflammation, in pediatric patients receiving peritoneal dialysis and hemodialysis. The medical records of pediatric dialysis patients who were followed-up in nine pediatric nephrology centers in Turkey between 2008 and 2013 were retrospectively reviewed. In addition to demographic data, we retrieved anthropometric measurements, data on dialysis treatment modalities, routine biochemical parameters, complete blood count, serum ferritin, parathormone, C-reactive protein (CRP), and albumin levels, as well as echocardiographic data and hospitalization records. The patients were divided into two groups based on their estimated glomerular filtration rate (eGFR) levels at dialysis initiation, namely, an early-start group, characterized by an eGFR of >10 ml/min/1.73 m 2 , and a late-start group, with an eGFR of < 7 ml/min/1.73 m 2 . The collected data were compared between these groups. A total of 245 pediatric dialysis patients (mean age ± standard deviation 12.3 ± 5.1 years, range 0.5-21 years) were enrolled in this study. Echocardiographic data were available for 137 patients, and the mean LV mass index (LVMI) was 58 ± 31 (range 21-215) g/m 2.7 . The LVMI was 75 ± 30 g/m 2.7 (n = 81) and 34 ± 6 g/m 2.7 (n = 56) in patients with or without LV hypertrophy (LVH) (p < 0.001). Early-start (eGFR >10 ml/min/1.73 m 2 ) versus late-start dialysis (eGFR < 7 ml/min/1.73 m 2 ) groups did not significantly differ in LVMI and LVH status (p > 0.05) nor in number of hospitalizations. Serum albumin levels were significantly higher in the early-dialysis group compared with the late-dialysis group (3.3 ± 0.7 vs. 3.1 ± 0.7 g/dl, respectively; p < 0.05). The early-start group had relatively

The Perception of Art among Patients and Staff on a Renal Dialysis Unit.

PubMed

Corrigan, C; Peterson, L; McVeigh, C; Lavin, P J; Mellotte, G J; Wall, C; Baker Kerrigan, A; Barnes, L; O'Neill, D; Moss, H

2017-10-10

This study investigated the purpose and effectiveness of giving outpatients an opportunity to engage in art activities while receiving dialysis treatment. A mixed method study was conducted. 21 semi-structured interviews were conducted with outpatients attending the dialysis unit and 13 surveys of clinicians were completed. The principle reasons to partake in the art activity programme included: to pass time, to relieve boredom, to be creative, to try something new, distraction from concerns, to stay positive and to achieve something new. Patients who did not participate in the programme pass their time primarily by watching TV or sleeping. All staff who partook in the survey were satisfied with the programme and wanted it to continue. Our findings indicate that the creative arts programme is viewed positively by staff and patients alike, and might be useful in other hospital departments. Further in depth qualitative research would be useful to interrogate the potential effect of engagement in art on positive mental health and quality of life for patients with chronic conditions.

Is Peritonitis Risk Increased in Elderly Patients on Peritoneal Dialysis? Report from the French Language Peritoneal Dialysis Registry (RDPLF).

PubMed

Duquennoy, Simon; Béchade, Clémence; Verger, Christian; Ficheux, Maxence; Ryckelynck, Jean-Philippe; Lobbedez, Thierry

2016-01-01

♦ This study was carried out to examine whether or not elderly patients on peritoneal dialysis (PD) had an increased risk of peritonitis. ♦ This was a retrospective cohort study based on data from the French Language Peritoneal Dialysis Registry. We analyzed 8,396 incident patients starting PD between January 2003 and December 2010. The end of the observation period was 31 December 2012. Patients were separated into 2 age groups: up to 75 and over of 75 years old. ♦ Among 8,396 patients starting dialysis there were 3,173 patients older than 75. When using a Cox model, no association was found between age greater than 75 years and increased risk of peritonitis (hazard ratio [HR]: 0.97 [0.88 - 1.07]). Diabetes (HR: 1.14 [1.01 - 1.28] and continuous ambulatory PD (HR: 1.13 [1.04 - 1.23]) were significantly associated with a higher risk of peritoneal infection whereas nurse-assisted PD was associated with a lower risk of peritonitis (HR: 0.85 [0.78 - 0.94]. In the analysis restricted to the 3,840 self-care PD patients, there was no association between age older than 75 years and risk of peritonitis. ♦ The risk of peritonitis is not increased in elderly patients on PD in a country where assisted PD is available. Copyright © 2016 International Society for Peritoneal Dialysis.

Sudden cardiac death in non-dialysis chronic kidney disease patients.

PubMed

Caravaca, Francisco; Chávez, Edgar; Alvarado, Raúl; García-Pino, Guadalupe; Luna, Enrique

2016-01-01

A relatively high proportion of deaths in dialysis patients occur suddenly and unexpectedly. The incidence of sudden cardiac death (SCD) in non-dialysis advanced chronic kidney disease (CKD) stages has been less well investigated. This study aims to determine the incidence and predictors of SCD in a cohort of 1078 patients with CKD not yet on dialysis. Prospective observational cohort study, which included patients with advanced CKD not yet on dialysis (stage 4-5). The association between baseline variables and SCD was assessed using Cox and competing-risk (Fine and Grey) regression models. Demographic, clinical information, medication use, and baseline biochemical parameters of potential interest were included as covariates. During the study period (median follow-up time 12 months), 210 patients died (19%), and SCD occurred in 34 cases (16% of total deaths). All-cause mortality and SCD incidence rates were 113 (95% CI: 99-128), and 18 (95% CI: 13-26) events per 1000 patients/year, respectively. By Cox regression analysis, covariates significantly associated with SCD were: Age, comorbidity index, and treatment with antiplatelet drugs. This latter covariate showed a beneficial effect over the development of SCD. By competing-risk regression, in which the competing event was non-sudden death from any cause, only age and comorbidity index remained significantly associated with SCD. SCD is relatively common in non-dialysis advanced CKD patients. SCD was closely related to age and comorbidity, and some indirect data from this study suggest that unrecognised or undertreated cardiovascular disease may predispose to a higher risk of SCD. Copyright © 2016 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.

Comparison between two physiotherapy protocols for patients with chronic kidney disease on dialysis

PubMed Central

Neto, José Roberto Sostena; Figueiredo e Castro, Letícia Magalhães; Santos de Oliveira, Fernanda; Silva, Andréia Maria; Maria dos Reis, Luciana; Quirino, Ana Paula Assunção; Dragosavac, Desanka; Kosour, Carolina

2016-01-01

[Purpose] To compare the effects of two physiotherapy protocols for chronic kidney disease patients on dialysis. [Subjects and Methods] This is a prospective, randomized study, in chronic kidney disease patients 18 years of age or older on dialysis. Sessions for each group (were conducted three times per week for a total of 10 sessions), during hemodialysis. Respiratory muscle strength (maximal inspiratory and expiratory pressure), peak expiratory flow, and peripheral muscle strength were evaluated. The study group received motor and respiratory physiotherapy, and the control group received motor physiotherapy alone. [Results] We observed a significant increase in the maximal inspiratory pressure in the study group in the 5th and 10th sessions and in the maximal expiratory pressure in the 1st session, peak flow in the 1st and 10th sessions, and dynamometry in the 10th session. In the control group, there was a significant decrease in maximal inspiratory pressure in the 5th and 10th sessions, and in maximal expiratory pressure in the 10th session, peak flow in the 5th and 10th sessions, and dynamometry in the 5th session. [Conclusion] Implementation of motor physiotherapy combined with respiratory physiotherapy may have contributed to the improvement of the variables analyzed in the study group. PMID:27313390

Leflunomide in dialysis patients with rheumatoid arthritis--a pharmacokinetic study.

PubMed

Bergner, Raoul; Peters, Lena; Schmitt, Verena; Löffler, Christian

2013-02-01

Pharmacokinetic data of disease modifying antirheumatic drugs during hemodialysis are limited to sulfasalazine, methotrexate, and cyclosporine. Only respective anecdotal data have been reported on leflunomide. We repeatedly measured teriflunomide (A77-1726), the active metabolite of leflunomide, during standard hemodialysis sessions and calculated teriflunomide clearances in five patients with rheumatoid arthritis (RA) and end-stage renal disease. The calculated teriflunomide clearances during a standardized dialysis session of 3-4.5 h at a blood flow rate of 160-300 ml/min were between 0 and 4.3 ml/min, the mean clearances of the total dialysis ranged between 1.1 and 3.4 ml/min. Total amount of teriflunomide removed was 5.8-8.8 μg per dialysis session. Dialytic removal of the active metabolite of leflunomide, teriflunomide (A77-1726), is negligible. Leflunomide can be used for RA patients on chronic dialysis without any dosage modification.

Comparison of erythrocyte membrane fatty acid contents in renal transplant recipients and dialysis patients.

PubMed

Oh, J S; Kim, S M; Sin, Y H; Kim, J K; Park, Y; Bae, H R; Son, Y K; Nam, H K; Kang, H J; An, W S

2012-12-01

Alterations of erythrocyte membrane fatty acid (FA) composition play important roles in cellular function because they change the membrane microenvironment, including transmembrane receptors. The erythrocyte membrane oleic acid content is higher among patients with acute coronary syndrome and also in dialysis patients. However, available data are limited concerning erythrocyte membrane FA content in kidney transplant recipients (KTP). We sought to test the hypothesis that erythrocyte membrane FA content among KTP were different from those in dialysis patients. In this cross-sectional study, we recruited 35 hemodialysis, 33 peritoneal dialysis 49 KTP, and 33 normal control subjects (CTL). Their erythrocyte membrane FA content were measured by gas chromatography. The mean ages of the enrolled dialysis patients, KTP, and CTL were 56.4 ± 10.1, 48.9 ± 10.4, and 49.5 ± 8.3 years, respectively. Mean kidney transplant duration was 89.8 ± 64.8 months and mean dialysis duration, 49.0 ± 32.6 months. The intakes of vegetable lipid and vegetable protein including total calories were significantly increased among KTP versus dialysis patients. Total cholesterol (P < .001) and high density lipoprotein cholesterol (HDL; P < .001) levels were significantly higher and C-reactive protein was significantly lower among KTP compared with dialysis patients. The erythrocyte membrane content of palmitoleic acid (P < .001) was significantly higher but oleic acid (P < .001) significantly lower in KTP compared with dialysis patients. The erythrocyte membrane contents of arachidonic acid and docosahexaenoic acid were significantly higher, and linoleic acid and the omega-6 FA to omega-3 FA ratio (P < .001) significantly lower in KTP compared with dialysis patients. The erythrocyte membrane content of oleic acid was independently associated with monounsaturated fatty acid (beta = 0.771, P < .001), eicosapentaeonic acid (beta = -0.244, P = .010), and HDL (beta = -0.139, P = .049) in KTP. FA

Epidemiological perspective on infections in chronic dialysis patients.

PubMed

Bloembergen, W E; Port, F K

1996-07-01

Infectious complications are a source of substantial morbidity and a common cause of death among dialysis patients. This article considers the magnitude and impact of the problem of infection among patients treated with hemodialysis (HD) and peritoneal dialysis (PD) using data from national registries and large cohort studies of patients with end-stage renal disease (ESRD). United States Renal Data System (USRDS) data indicate that in the United States for years 1991 to 1992, infection accounted for 12% of all deaths among HD patients and 15% of all deaths among PD patients. Septicemia was the underlying cause in 76% of these infectious deaths among HD patients, of which the vascular access, peritonitis, peripheral vascular disease, and other causes accounted for 12%, 5%, 24%, and 59% respectively. Among PD patients, septicemia accounted for 79% of infectious deaths. Of these deaths attributable to septicemia, peritonitis, peripheral vascular disease, and other causes were reported as the cause in 35%, 23%, and 41% respectively. Infection is also a major cause of morbidity in the dialysis population. Among HD patients, an average of 7.6 bacteremic episodes per 100 patient years (0.076 per year) has been described, of which 48% were associated with access infections. Among PD patients, studies have reported peritonitis rates ranging from 1 in 7.6 to 21.5 months (0.56 to 1.58 per patient year) and exit and/or tunnel infections occurring at a rate of 0.6 episodes per year. The known predictors of infectious complications among these populations are reviewed.

Peritoneal dialysis in Mexico.

PubMed

Cueto-Manzano, Alfonso M

2003-02-01

While Mexico has the thirteenth largest economy, a large portion of the population is impoverished. About 90% of the population is Mestizo, the result of the admixture of Mexican Indians and Spaniards, with the Indigenous peoples concentrated in the southeastern region. Treatment for end-stage renal disease (estimated 268 patients per million population) is largely determined by the limited healthcare system and the individual's access to resources such as private insurance ( approximately 15%) and governmental sources ( approximately 85%). With only 5% of the gross national product spent on healthcare and most treatment providers being public health institutions that are often under severe economic restrictions, it is not surprising that many Mexican patients do not receive renal replacement therapy. Mexico uses proportionately more peritoneal dialysis than other countries; 1% of the patients are on automated peritoneal dialysis, 19% on hemodialysis and 80% on CAPD. Malnutrition and diabetes, important risk factors for poor outcome, are prevalent among the patients in CAPD programs.

Choosing to live with home dialysis-patients' experiences and potential for telemedicine support: a qualitative study

PubMed Central

2012-01-01

Background This study examines the patients' need for information and guidance in the selection of dialysis modality, and in establishing and practicing home dialysis. The study focuses on patients' experiences living with home dialysis, how they master the treatment, and their views on how to optimize communication with health services and the potential of telemedicine. Methods We used an inductive research strategy and conducted semi-structured interviews with eleven patients established in home dialysis. Our focus was the patients' experiences with home dialysis, and our theoretical reference was patients' empowerment through telemedicine solutions. Three informants had home haemodialysis (HHD); eight had peritoneal dialysis (PD), of which three had automated peritoneal dialysis (APD); and five had continuous ambulatory peritoneal dialysis (CAPD). The material comprises all PD-patients in the catchment area capable of being interviewed, and all known HHD-users in Norway at that time. Results All of the interviewees were satisfied with their choice of home dialysis, and many experienced a normalization of daily life, less dominated by disease. They exhibited considerable self-management skills and did not perceive themselves as ill, but still required very close contact with the hospital staff for communication and follow-up. When choosing a dialysis modality, other patients' experiences were often more influential than advice from specialists. Information concerning the possibility of having HHD, including knowledge of how to access it, was not easily available. Especially those with dialysis machines, both APD and HHD, saw a potential for telemedicine solutions. Conclusions As home dialysis may contribute to a normalization of life less dominated by disease, the treatment should be organized so that the potential for home dialysis can be fully exploited. Pre-dialysis information should be unbiased and include access to other patients' experiences. Telemedicine

Barriers to Increasing Use of Peritoneal Dialysis in Bangladesh: A Survey of Patients and Providers.

PubMed

Savla, Dipal; Ahmed, Sweety; Yeates, Karen; Matthew, Anna; Anand, Shuchi

2017-01-01

Despite a lower requirement for technology and equipment than hemodialysis (HD), peritoneal dialysis (PD) is an underutilized modality in low- and middle-income countries (LMICs). Bangladesh has the lowest use of PD in the world (fewer than 2% of prevalent patients). We evaluated nephrologists' attitudes toward PD and examined differences between patients on HD and PD in Dhaka. We asked nephrologists to fill out an English-language questionnaire. Using convenience sampling but targeting both public and private hospitals in Dhaka, we asked trained nurses to administer a Bangla-language questionnaire to patients on HD ( n = 116) and PD ( n = 41). We validated the questionnaires on a sub-sample ( n = 10 for each group). Of the 43 nephrologists surveyed, 27 (63%) had patients on PD. When compared with nephrologists without patients on PD, those with patients on PD were less likely to believe that survival and quality of life on PD was worse than on HD (odds ratio [OR] = 0.21, 95% confidence interval [CI] 0.05 - 0.83 and OR = 0.11, 95% CI 0.02 - 0.67 respectively) but were not more likely to have received training for PD. Nephrologists named cost of PD as the predominant barrier to increasing use of PD, followed by concerns about patient hygiene and lack of trained nurses. Fifty-two HD patients (45%) did not know about a home-based modality. When compared with patients on HD, patients on PD were more likely to have been educated by non-nephrologists about dialysis, to be "forewarned" about the need for dialysis, to be paying fully, and to be living in a permanent home with a non-communal water source. Some barriers to increasing access to PD-i.e., patient living conditions and cost-are unique to LMICs. Our study also highlights that issues encountered in high-income countries-i.e., nephrologists' subjective preference and lack of patient knowledge about an alternate modality to HD-may play a role as well. Copyright © 2017 International Society for Peritoneal Dialysis.

Outcome of patients with hemodialysis or peritoneal dialysis undergoing simultaneous pancreas-kidney transplantation. Comparative study.

PubMed

Marcacuzco, Alberto; Jiménez-Romero, Carlos; Manrique, Alejandro; Calvo, Jorge; Cambra, Félix; Caso, Óscar; García-Sesma, Álvaro; Nutu, Anisa; Justo, Iago

2018-06-01

Controversy remains with regard to the higher risk of intra-abdominal infections and lower patient and graft survival when peritoneal dialysis (PD) rather than hemodialysis (HD) is used in simultaneous pancreas-kidney transplantation (SPKT). From March 1995 to December 2015, we performed 165 SPKTs. Prior to transplant, patients received hemodialysis (group HD; n = 98) or peritoneal dialysis (group PD; n = 67). A comparison was made to analyze post-transplant complications and patient, pancreas, and kidney graft survivals. Donor, pretransplant, and perioperative recipient variables were similar in both groups. Overall rates of infections (69.4% in HD vs 73.1% in PD; P = .50) and intra-abdominal infections (31.6% in HD vs 35.8 in PD; P = .57) were similar in both groups. The rates of pancreatitis, hemorrhage or thrombosis of the graft, duodenal graft leak, relaparotomy, transplantectomy, pancreas rejection, and retransplantation were similar in both groups. Patient survival at 1, 3, and 5 years (95.9%, 93.9%, and 93.9% in HD vs 95.5%, 92.2%, and 90.4% in PD; P = .54) and pancreas graft survival (83.6%, 78.0%, and 71.8% in HD vs 79.2%, 77.4%, and 71.0% in PD; P = .8) were similar in both groups. Kidney graft survival was similar in both groups. Pancreas graft thrombosis, rejection, and relaparotomy for intra-abdominal complications were independent predictors of lower pancreas graft survival, but dialysis modality did not influence patient or graft survival. Pre-SPKT modality of dialysis does not significantly influence overall or intra-abdominal infection and patient, pancreas, or kidney graft survivals. © 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Variation in Nephrologist Visits to Patients on Hemodialysis across Dialysis Facilities and Geographic Locations

PubMed Central

Tan, Kelvin B.; Winkelmayer, Wolfgang C.; Chertow, Glenn M.; Bhattacharya, Jay

2013-01-01

Summary Background and objectives Geographic and other variations in medical practices lead to differences in medical costs, often without a clear link to health outcomes. This work examined variation in the frequency of physician visits to patients receiving hemodialysis to measure the relative importance of provider practice patterns (including those patterns linked to geographic region) and patient health in determining visit frequency. Design, setting, participants, & measurements This work analyzed a nationally representative 2006 database of patients receiving hemodialysis in the United States. A variation decomposition analysis of the relative importance of facility, geographic region, and patient characteristics—including demographics, socioeconomic status, and indicators of health status—in explaining physician visit frequency variation was conducted. Finally, the associations between facility, geographic and patient characteristics, and provider visit frequency were measured using multivariable regression. Results Patient characteristics accounted for only 0.9% of the total visit frequency variation. Accounting for case-mix differences, patients’ hemodialysis facilities explained about 24.9% of visit frequency variation, of which 9.3% was explained by geographic region. Visit frequency was more closely associated with many facility and geographic characteristics than indicators of health status. More recent dialysis initiation and recent hospitalization were associated with decreased visit frequency. Conclusions In hemodialysis, provider visit frequency depends more on geography and facility location and characteristics than patients’ health status or acuity of illness. The magnitude of variation unrelated to patient health suggests that provider visit frequency practices do not reflect optimal management of patients on dialysis. PMID:23430207

A survey of views and practice patterns of dialysis medical directors toward end-of-life decision making for patients with end-stage renal disease.

PubMed

Fung, Enrica; Slesnick, Nate; Kurella Tamura, Manjula; Schiller, Brigitte

2016-07-01

Patients with end-stage renal disease report infrequent end-of-life discussions, and nephrology trainees report feeling unprepared for end-of-life decision making, but the views of dialysis medical directors have not been studied. Our objective is to understand dialysis medical directors' views and practice patterns on end-of-life decision making for patients with ESRD. We administered questionnaires to dialysis medical directors during medical director meetings of three different dialysis organizations in 2013. Survey questions corresponded to recommendations from the Renal Physicians Association clinical practice guidelines on initiation and withdrawal of dialysis. There were 121 medical director respondents from 28 states. The majority of respondents felt "very prepared" (66%) or "somewhat prepared" (29%) to participate in end-of-life decisions and most (80%) endorsed a model of shared decision making. If asked to do so, 70% of the respondents provided prognostic information "often" or "nearly always." For patients with a poor prognosis, 36% of respondents would offer a time-limited trial of dialysis "often" or "nearly always", while 56% of respondents would suggest withdrawal from dialysis "often" or "nearly always" for those with a poor prognosis currently receiving dialysis therapy. Patient resistance and fear of taking away hope were the most commonly cited barriers to end-of-life discussions. Views and reported practice patterns of medical directors are consistent with clinical practice guidelines for end-of-life decision making for patients with end-stage renal disease but inconsistent with patient perceptions. © The Author(s) 2016.

Patient and family perspectives on peritoneal dialysis at home: findings from an ethnographic study.

PubMed

Baillie, Jessica; Lankshear, Annette

2015-01-01

To discuss findings from an ethnographic study, considering the experiences of patients and families, using peritoneal dialysis at home in the United Kingdom. Peritoneal dialysis is a daily, life-preserving treatment for end-stage renal disease, undertaken in the patient's home. With ever-growing numbers of patients requiring treatment for this condition, the increased use of peritoneal dialysis is being promoted. While it is known that quality of life is reduced when using dialysis, few studies have sought to explore experiences of peritoneal dialysis specifically. No previous studies were identified that adopted an ethnographic approach. A qualitative design was employed, utilising ethnographic methodology. Ethical and governance approvals were gained in November 2010 and data were generated in 2011. Patients (n = 16) and their relatives (n = 9) were interviewed and observed using peritoneal dialysis in their homes. Thematic analysis was undertaken using Wolcott's (1994) three stage process: Description, Analysis and Interpretation. This article describes four themes: initiating peritoneal dialysis; the constraints of peritoneal dialysis due to medicalisation of the home environment and the imposition of rigid timetables; the uncertainty of managing crises and inevitable deterioration; and seeking freedom through creativity and hope of a kidney transplant. This study highlights the culture of patients and their families living with peritoneal dialysis. Despite the challenges posed by the treatment, participants were grateful they were able to self-manage at home. Furthermore, ethnographic methods offer an appropriate and meaningful way of considering how patients live with home technologies. Participants reported confusion about kidney transplantation and also how to identify peritonitis, and ongoing education from nurses and other healthcare professionals is thus vital. Opportunities for sharing experiences of peritoneal dialysis were valued by participants and

Asymptomatic Effluent Protozoa Colonization in Peritoneal Dialysis Patients.

PubMed

Simões-Silva, Liliana; Correia, Inês; Barbosa, Joana; Santos-Araujo, Carla; Sousa, Maria João; Pestana, Manuel; Soares-Silva, Isabel; Sampaio-Maia, Benedita

Currently, chronic kidney disease (CKD) is a global health problem. Considering the impaired immunity of CKD patients, the relevance of infection in peritoneal dialysis (PD), and the increased prevalence of parasites in CKD patients, protozoa colonization was evaluated in PD effluent from CKD patients undergoing PD. Overnight PD effluent was obtained from 49 asymptomatic stable PD patients. Protozoa analysis was performed microscopically by searching cysts and trophozoites in direct wet mount of PD effluent and after staining smears. Protozoa were found in PD effluent of 10.2% of evaluated PD patients, namely Blastocystis hominis, in 2 patients, and Entamoeba sp., Giardia sp., and Endolimax nana in the other 3 patients, respectively. None of these patients presented clinical signs or symptoms of peritonitis at the time of protozoa screening. Our results demonstrate that PD effluent may be susceptible to asymptomatic protozoa colonization. The clinical impact of this finding should be further investigated. Copyright © 2016 International Society for Peritoneal Dialysis.

Liver enzymes in patients with chronic kidney disease undergoing peritoneal dialysis and hemodialysis.

PubMed

Liberato, Isabella Ramos de Oliveira; Lopes, Edmundo Pessoa de Almeida; Cavalcante, Maria Alina Gomes de Mattos; Pinto, Tiago Costa; Moura, Izolda Fernades; Loureiro Júnior, Luiz

2012-01-01

The present study was designed to analyze the serum levels of aspartate and alanine aminotransferases, gamma-glutamyl transferase, and the hematocrit in patients with chronic kidney disease who were undergoing peritoneal dialysis or hemodialysis. Twenty patients on peritoneal dialysis and 40 on hemodialysis were assessed, and the patients were matched according to the length of time that they had been on dialysis. Blood samples were collected (both before and after the session for those on hemodialysis) to measure the enzymes and the hematocrit. In the samples from the patients who were undergoing peritoneal dialysis, the aspartate and alanine aminotransferase levels were slightly higher compared with the samples collected from the patients before the hemodialysis session and slightly lower compared with the samples collected after the hemodialysis session. The levels of gamma-glutamyl transferase in the hemodialysis patients were slightly higher than the levels in the patients who were undergoing peritoneal dialysis. In addition, the levels of aminotransferases and gamma-glutamyl transferase that were collected before the hemodialysis session were significantly lower than the values collected after the session. The hematocrit levels were significantly lower in the patients who were on peritoneal dialysis compared with the patients on hemodialysis (both before and after the hemodialysis session), and the levels were also significantly lower before hemodialysis compared with after hemodialysis. The aminotransferase levels in the patients who were undergoing peritoneal dialysis were slightly higher compared with the samples collected before the hemodialysis session, whereas the aminotransferase levels were slightly lower compared with the samples collected after the session. The hematocrits and the aminotransferase and gamma-glutamyl transferase levels of the samples collected after the hemodialysis session were significantly higher than the samples collected before

Hypomagnesemia Is Associated with Increased Mortality among Peritoneal Dialysis Patients

PubMed Central

Dai, Zhiwei; Zhu, Beixia; Fei, Jinping; Xue, Congping; Wu, Dan

2016-01-01

Objective Hypomagnesemia has been associated with an increase in mortality among the general population as well as patients with chronic kidney disease or those on hemodialysis. However, this association has not been thoroughly studied in patients undergoing peritoneal dialysis. The aim of this study was to evaluate the association between serum magnesium concentrations and all-cause and cardiovascular mortalities in peritoneal dialysis patients. Methods This single-center retrospective study included 253 incident peritoneal dialysis patients enrolled between July 1, 2005 and December 31, 2014 and followed to June 30, 2015. Patient’s demographic characteristics as well as clinical and laboratory measurements were collected. Results Of 253 patients evaluated, 36 patients (14.2%) suffered from hypomagnesemia. During a median follow-up of 29 months (range: 4–120 months), 60 patients (23.7%) died, and 35 (58.3%) of these deaths were attributed to cardiovascular causes. Low serum magnesium was positively associated with peritoneal dialysis duration (r = 0.303, p < 0.001) as well as serum concentrations of albumin (r = 0.220, p < 0.001), triglycerides (r = 0.160, p = 0.011), potassium (r = 0.156, p = 0.013), calcium(r = 0.299, p < 0.001)and phosphate (r = 0.191, p = 0.002). Patients in the hypomagnesemia group had a lower survival rate than those in the normal magnesium groups (p < 0.001). In a multivariate Cox proportional hazards regression analysis, serum magnesium was an independent negative predictor of all-cause mortality (hazard ratio [HR] = 0.075, p = 0.011) and cardiovascular mortality (HR = 0.003, p < 0.001), especially in female patients. However, in univariate and multivariate Cox analysis, △Mg(difference between 1-year magnesium and baseline magnesium) was not an independent predictor of all-cause mortality and cardiovascular mortality. Conclusion Hypomagnesemia was common among peritoneal dialysis patients and was independently associated with all

Exploring the relationships between patient characteristics and their dialysis care experience.

PubMed

van der Veer, Sabine N; Arah, Onyebuchi A; Visserman, Ella; Bart, Hans A J; de Keizer, Nicolette F; Abu-Hanna, Ameen; Heuveling, Lara M; Stronks, Karien; Jager, Kitty J

2012-11-01

Previous studies have shown that it is possible for patient experience to be influenced by factors that are not attributable to health-care. Therefore, if patient experience is to be used as an accurate indicator of clinical performance, then it is important to understand its determinants. We used data from 840 dialysis patients who completed a validated patient experience survey. We created a potential theoretical framework based on available clinical knowledge to hypothesize the relationships between 13 demographic, socio-economic and health status factors and three outcome measures: global rating of the dialysis centre and the patient experience with the nephrologist's and nurses' care. The theoretical framework guided the selection of confounding variables for each determinant, which were then entered as terms in multivariable linear regression models. Patients who were of older age, of non-European decent, and who had a lower educational level, lower albumin level, with better self-rated health and who were without co-morbidities reported higher global ratings with the dialysis centre than their counterparts. Past myocardial infarction and better self-rated health were found to be determinants of a more positive experience while in the nephrologist's care. A more positive experience with nurses' care was associated with factors including older age, Dutch origin background, lower educational level, lower albumin levels and better self-rated health. Several characteristics of dialysis patients influence the way they rate and experience their care. When using the patient experience and ratings as indicators of clinical performance, they should be adjusted for such factors as identified in our study. This will facilitate a meaningful comparison of dialysis centres, and enable informed decision making by patients, insurers and policy makers.

Hydration and nutritional status in patients on home-dialysis-A single centre study.

PubMed

Li, Janet S C; Chan, John Y H; Tai, Mandy M Y; Wong, So M; Pang, S M; Lam, Fanny Y F; Chu, Carmen H M; Ching, Chris S Y; Wong, Joseph H S; Chak, W L

2018-04-17

Over-hydration (OH) and malnutrition are prevalent among patients on dialysis therapy. The prevalence of OH and malnutrition as well as the risk factors associated with OH and malnutrition in our patients on home peritoneal dialysis (PD) and home haemodialysis (HD) are examined. This was a cross-sectional study. The hydration and nutritional status of the study groups were assessed by a Body Composition Monitor. Patients who were stable on home dialysis therapy for over one year were invited to participate. Univariate and multivariate analyses were performed to identify associated factors and determine the predictors of OH and malnutrition, respectively. Eighty-eight patients (41 PD and 47 home HD) were recruited. A 32.95% of our patients on home dialysis therapy were in OH status. There was a significance difference in the prevalence of hydration status between patients on PD and home HD (p = 0.014), as overhydration was more common in patients on PD than home HD (46.34 vs. 21.28%). Dehydration was more common in patients on home HD than PD (29.79 vs. 9.76%). Male gender, decreasing haemoglobin level and presence of diabetes mellitus (DM) were risk factors of OH on multivariable analysis. There was no significance difference in the prevalence of malnutrition between patients on PD and home HD (p = 0.27). Increasing Fat Tissue Index (FTI), height and patients on PD therapy were at higher risk of malnutrition. OH and malnutrition were prevalent patients on home dialysis therapy. © 2018 European Dialysis and Transplant Nurses Association/European Renal Care Association.

Dialysis staff encouragement and fluid control adherence in patients on hemodialysis.

PubMed

Yokoyama, Yoko; Suzukamo, Yoshimi; Hotta, Osamu; Yamazaki, Shin; Kawaguchi, Takehiko; Hasegawa, Takeshi; Chiba, Shigemi; Moriya, Toshiko; Abe, Emi; Sasaki, Satoshi; Haga, Megumi; Fukuhara, Shunichi

2009-01-01

Fluid control in patients on dialysis is an important predictor of outcome but is a difficult restriction to achieve. The authors examined the association between dialysis staff encouragement and fluid control adherence in patients on hemodialysis. This cross-sectional study used the dialysis staff encouragement subscale (DSE). The outcome measure was intradialytic weight loss (IWL) of dry weight (DW), with nonadherence defined as IWL/DW greater than 5.7%. Predictors of nonadherence were identified using logistic regression. Odds ratio (OR) was for the occurrence of nonadherence as it correlated with a one standard deviation (SD) decrease in scale score. Seventy-two patients on hemodialysis participated, 45 men (62.5%) and 27 women. The crude OR in DSE score was 1.75 (95% confidence interval [CI]: 1.02 to 3.0) and adjusted odds ratio was 2.51 (95% CI: 0.99 to 6.34). Dialysis staff encouragement is important in improving fluid control adherence.

Multicentre study of treatment outcomes in Australian adolescents and young adults commencing dialysis.

PubMed

Krischock, Leah; Kennedy, Sean E; Hayen, Andrew

2017-12-01

The aim of the study is to improve the understanding of outcomes and complications of dialysis in adolescents and young adults (AYA) to inform decisions about dialysis modality in this patient population. Registry data on Australian AYA aged 13 to 20 years who commenced dialysis between 1/1/2000 and 31/12/2013 were retrieved from the Australia and New Zealand Dialysis and Transplantation Registry and analyzed to determine associations between demographic characteristics, dialysis modality and outcomes. During the study period 300 AYA commenced dialysis at a median age of 17.2 years (IQR 15.6 to 18.6 years). Haemodialysis (HD) was the initial dialysis modality in 201 patients (67%). No significant differences between AYA receiving HD and peritoneal dialysis (PD) were noted in patient gender, age, race, primary renal disease, treating centre type, remoteness of residential area, lateness of referral or period of study. Mean haemoglobin levels were lower in the HD group (P = 0.005) and significantly fewer HD patients attended school full time compared to patients managed on PD (P = 0.002 first year; P = 0.05 second year). Dialysis modality choice does not appear to be influenced by patient characteristics nor dialysis outcomes. Future research is required to examine the reasons that HD is preferred over PD and to determine the optimal method of dialysis for this age group. © 2016 Asian Pacific Society of Nephrology.

Timing of start of dialysis in diabetes mellitus patients: a systematic literature review.

PubMed

Nacak, Hakan; Bolignano, Davide; Van Diepen, Merel; Dekker, Friedo; Van Biesen, Wim

2016-02-01

Diabetes mellitus is a frequent cause of the need for renal replacement therapy (RRT). Historically, RRT was started earlier in patients with diabetes, in an attempt to prevent complications of uraemia and diabetes. We did a systematic review to find support for this earlier start of dialysis in patients with versus without diabetes. The MEDLINE, EMBASE and CENTRAL databases were searched for articles about the timing of dialysis initiation in (subgroups of) patients with diabetes and CKD Stage 5. A total of 340 papers were screened and 11 papers were selected to be reviewed. Only three studies showed data of at least one subgroup of patients with diabetes. Two observational studies concluded that start of dialysis with a higher estimated glomerular filtration rate (eGFR) is beneficial with regard to survival, one did not find a difference and six observational studies concluded that start of dialysis with a lower eGFR is associated with better survival in patients with diabetes. The effect of timing of initiation of dialysis did not differ between patients with versus without diabetes. Lastly, one randomized controlled trial (two papers) reported that there was no difference in survival between start at higher versus lower eGFR overall and a P-value for the interaction with diabetes of P = 0.63, indicating no difference between patients with versus without diabetes with regard to the timing of start of dialysis and subsequent mortality on dialysis. There is no difference between early (eGFR) and late (lower eGFR) start of RRT with regard to mortality in patients with versus without diabetes. RRT should thus be initiated based on the same criteria in all patients, irrespective of the presence or absence of diabetes. © The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Systemic and intraperitoneal proinflammatory cytokines profiles in patients on chronic peritoneal dialysis.

PubMed

Maksić, Doko; Colić, Miodrag; Stanković-Popović, Verica; Radojević, Milorad; Bokonjić, Dubravko

2007-01-01

Cytokines are essential mediators of immune response and inflammatory reactions. Patients with chronic renal failure and on Continuous Ambulatory Peritoneal Dialysis commonly present abnormalities of immune function related to impaired kidney function, accumulation of uremic toxins and bioincompatibility of peritoneal dialysis solutions. Aim of this study was to examine effects of the CAPD solutions (standard v.s. biocompatible), as well as dialysis duration upon the local and systemic profile of the pro-inflammatory cytokines (IL-1, TNF and IL-6) in patients on CAPD. The cross-sectional study included 44 CAPD patients (27 M and 17 F, average mean age 57.12+/-16.66), of whom 21 patients were on the standard solutions (A.N.D.Y.Disc) for peritoneal dialysis and 23 on the biocompatible solutions (Gambrosol bio trio, Stay Safe balance). The average dialysis treatment period was 3.59+/-2.67 years. In all CAPD patients dialysed longer than 6 months, levels of IL-1. TNF and IL-6 in the serum and dialysis effluent were analysed in the phase without acute infection-related complications (CAPD peritonitis, infection of the catheter exit-site, other acute infections). The control group included 20 patients with the CRF (stage IV and V) whose serum levels of the examined cytokines were also determined. Levels of the inflammatory cytokines were measured by commercial specific ELISA kits (BioSource, Camarillo, California, USA). Statistical analysis of the obtained results was performed by commercial statistics PC software (Stat for Windows, R.4.5. SAD). The serum IL-1 and IL-6 levels were not statistically significantly different in patients on CAPD, irrespective of the type of the used dialysis solutions and in the control group of patients with CRF. The serum TNF levels, unlike IL-1 and IL-6, were statistically significantly higher in patients on CAPD in comparison with the control group of patients (13.203.23 v.s. 5.594.54, p< 0.001, Mann Whitney test). The serum and effluent

Malnutrition-inflammation-coronary calcification in pediatric patients receiving chronic hemodialysis.

PubMed

Srivaths, Poyyapakkam R; Silverstein, Douglas M; Leung, Jocelyn; Krishnamurthy, Rajesh; Goldstein, Stuart L

2010-07-01

Malnutrition, inflammation, and renal osteodystrophy parameters with resultant coronary calcification (CC) are associated with increased cardiovascular mortality in adults. Previous pediatric studies demonstrated CC in children but none assessed for an association between inflammation, malnutrition, renal osteodystrophy, and CC. To assess CC, ultrafast computerized tomogram was obtained for 16 pediatric patients (6 females; median age 17.2 years; range 9.1-21.2 years) receiving hemodialysis for >/=2 months. Inflammation was assessed by serum IL-6, IL-8, and C-reactive protein levels on the day of the computerized tomogram scan; nutrition parameters included serum albumin, cholesterol, the body mass index standard deviation score, and normalized protein catabolic rate. Renal osteodystrophy parameters included time-averaged serum calcium, phosphorus, total PTH, and calcitriol/calcium dose. Patients received hemodialysis thrice-weekly; mean single pool Kt/V 1.48+/-0.13; and mean normalized protein catabolic rate 1.27+/-0.17 g/kg/day. Five of 16 patients had CC. Patients with CC were older (19.1+/-2.1 vs. 15.4+/-3.1 months; P=0.03), had longer dialysis vintage (49.4+/-15.3 vs. 17.2+/-10.5 months, P=0.0002), lower serum cholesterol (122+/-17.7 vs. 160.4+/-10.6 mg/dL, P=0.02), and higher phosphorus (9.05+/-1.2 vs. 6.1+/-0.96 mg/dL, P=0.0001). Mean serum albumin and normalized protein catabolic rate did not differ for patients with CC. All patients had elevated IL-6 and IL-8 levels compared with healthy norms; the mean IL-6, IL-8, and C-reactive protein levels were not different in patients with CC. Coronary calcification was prevalent in older children receiving maintenance hemodialysis with a longer dialysis vintage. Worse renal osteodystrophy control and malnutrition (low cholesterol) may contribute to CC development.

The financial impact of increasing home-based high dose haemodialysis and peritoneal dialysis.

PubMed

Liu, Frank Xiaoqing; Treharne, Catrin; Culleton, Bruce; Crowe, Lydia; Arici, Murat

2014-10-02

Evidence suggests that high dose haemodialysis (HD) may be associated with better health outcomes and even cost savings (if conducted at home) versus conventional in-centre HD (ICHD). Home-based regimens such as peritoneal dialysis (PD) are also associated with significant cost reductions and are more convenient for patients. However, the financial impact of increasing the use of high dose HD at home with an increased tariff is uncertain. A budget impact analysis was performed to investigate the financial impact of increasing the proportion of patients receiving home-based dialysis modalities from the perspective of the England National Health Service (NHS) payer. A Markov model was constructed to investigate the 5 year budget impact of increasing the proportion of dialysis patients receiving home-based dialysis, including both high dose HD at home and PD, under the current reimbursement tariff and a hypothetically increased tariff for home HD (£575/week). Five scenarios were compared with the current England dialysis modality distribution (prevalent patients, 14.1% PD, 82.0% ICHD, 3.9% conventional home HD; incident patients, 22.9% PD, 77.1% ICHD) with all increases coming from the ICHD population. Under the current tariff of £456/week, increasing the proportion of dialysis patients receiving high dose HD at home resulted in a saving of £19.6 million. Conducting high dose HD at home under a hypothetical tariff of £575/week was associated with a budget increase (£19.9 million). The costs of high dose HD at home were totally offset by increasing the usage of PD to 20-25%, generating savings of £40.0 million - £94.5 million over 5 years under the increased tariff. Conversely, having all patients treated in-centre resulted in a £172.6 million increase in dialysis costs over 5 years. This analysis shows that performing high dose HD at home could allow the UK healthcare system to capture the clinical and humanistic benefits associated with this therapy while

Molecular adsorbent recirculating system dialysis in patients with acute liver failure who are assessed for liver transplantation.

PubMed

Camus, Christophe; Lavoué, Sylvain; Gacouin, Arnaud; Le Tulzo, Yves; Lorho, Richard; Boudjéma, Karim; Jacquelinet, Christian; Thomas, Rémi

2006-11-01

To assess the usefulness of dialysis with the molecular adsorbent recirculating system (MARS) in patients with acute liver failure who fulfil criteria for liver transplantation. Observational cohort study. ICU at a liver transplantation centre. Twenty-two patients (23 episodes) received MARS dialysis. They were either listed for LT (n=14), delayed (n=1), or not listed (contra-indication, n=7). A total of 56 MARS treatments (median per patient 2; mean duration 7.6+/-2.6h) were performed on haemodialysis. Clinical and biological variables were assessed before and 24[Symbol: see text]h after MARS therapy. The rate of recovery of liver function without transplantation was compared with an expected rate and survival was analysed. Following MARS dialysis, we observed an improvement in the grade of hepatic encephalopathy (P=0.02) and the Glasgow coma score (P=0.02), a decrease in conjugated bilirubin (P=0.05) and INR (P=0.006), and an increase in prothrombin index (P=0.005). Overall, liver function improved in seven patients (32%): four listed patients in whom transplantation could be avoided and three patients among those not listed due to contra-indications. The transplant-free recovery rate in listed patients was 29% (vs. expected 9%, P=0.036). Listed patients (n=14) had a higher 30-day survival rate [86% (12/14) vs 38% (3/8), P=0.05] and a higher long-term survival rate (P=0.02). A statistically significant improvement of liver function was observed after MARS therapy. Transplant-free recovery was more frequent than expected. The apparent benefit of MARS dialysis to treat acute liver failure needs to be confirmed by a controlled study.

Geovariation in Fracture Risk among Patients Receiving Hemodialysis

PubMed Central

Liu, Jiannong; Wirtz, Heidi S.; Gilbertson, David T.; Cooper, Kerry; Nieman, Kimberly M.; Collins, Allan J.; Bradbury, Brian D.

2016-01-01

Background and objectives Fractures are a major source of morbidity and mortality in patients receiving dialysis. We sought to determine whether rates of fractures and tendon ruptures vary geographically. Design, setting, participants, & measurements Data from the US Renal Data System were used to create four yearly cohorts, 2007–2010, including all eligible prevalent patients on hemodialysis in the United States on January 1 of each year. A secondary analysis comprising patients in a large dialysis organization conducted over the same period permitted inclusion of patient-level markers of mineral metabolism. Patients were grouped into 10 regions designated by the Centers for Medicare and Medicaid Services and divided by latitude into one of three bands: south, <35°; middle, 35° to <40°; and north, ≥40°. Poisson regression was used to calculate unadjusted and adjusted region–level rate ratios for events. Results Overall, 327,615 patients on hemodialysis were included. Mean (SD) age was 61.8 (15.0) years old, 52.7% were white, and 55.0% were men. During 716,962 person-years of follow-up, 44,014 fractures and tendon ruptures occurred, the latter being only 0.3% of overall events. Event rates ranged from 5.36 to 7.83 per 100 person-years, a 1.5-fold rate difference across regions. Unadjusted region–level rate ratios varied from 0.83 (95% confidence interval, 0.81 to 0.85) to 1.20 (95% confidence interval, 1.18 to 1.23), a 1.45-fold rate difference. After adjustment for a wide range of case mix variables, a 1.33-fold variation in rates remained. Rates were higher in north and middle bands than the south (north rate ratio, 1.18; 95% confidence interval, 1.13 to 1.23; middle rate ratio, 1.13; 95% confidence interval, 1.10 to 1.17). Latitude explained 11% of variation, independent of region. A complementary analysis of 87,013 patients from a large dialysis organization further adjusted for circulating mineral metabolic parameters and protein energy wasting

Accepting or declining dialysis: considerations taken into account by elderly patients with end-stage renal disease.

PubMed

Visser, Annemieke; Dijkstra, Geke J; Kuiper, Daphne; de Jong, Paul E; Franssen, Casper F M; Gansevoort, Ron T; Izaks, Gerbrand J; Jager, Kitty J; Reijneveld, Sijmen A

2009-01-01

Elderly patients with end-stage renal disease have to make a difficult decision whether or not to start dialysis. This study explores the considerations taken into account by these patients in decision-making regarding renal replacement therapy. In-depth interviews were conducted to gain an enhanced understanding of the considerations in treatment decision-making. Fourteen patients aged 65 years or older participated in the interviews, of whom 8 patients had made the decision to start, and 6 patients the decision to decline, dialysis. All participating patients had a variety of health problems, but appeared to have normal cognitive functions. Patients who declined dialysis were older and more often men and widow(er)s compared with patients who accepted dialysis. Patients chose to start dialysis because they enjoyed life, were not prepared to face the end of life, felt they had no other choice or had care-giving responsibilities for family members. Patients declined dialysis because of the speculated loss of autonomy, their age-associated decrease in vitality, distance from dialysis center and reluctance to think about the future. Results suggest that patients' decisions to decline or accept dialysis are not based on the effectiveness of the treatment, but rather on personal values, beliefs and feelings toward life, suffering and death, and the expected difficulties in fitting the treatment into their life.

Alternative medicine use in dialysis patients: potential for good and bad!

PubMed

Duncan, Heather J; Pittman, Susan; Govil, Amit; Sorn, Lisa; Bissler, Gloria; Schultz, Tersea; Faith, J; Kant, Shashi; Roy-Chaudhury, Prabir

2007-01-01

Although alternative medicines are widely used within the general population, the extent of their use within the dialysis population is unknown. It is possible that dialysis patients may be more likely to turn towards alternative therapies in view of the chronicity of their disease. In addition, this particular patient population could be at an increased risk of toxicity from these therapies due to an absence of renal excretion. A detailed assessment of complementary and alternative medicine use in our dialysis patients revealed that 18% of our patients had used or were using some form of alternative medicine therapy. An additional 63% of our patients, however, were willing to use a complementary or alternative medication. Our results suggest that hemodialysis patients are extremely receptive to the use of such therapies and are therefore exposed to all their potential benefit and harm. Copyright 2007 S. Karger AG, Basel.

Association of impaired baroreflex sensitivity and increased arterial stiffness in peritoneal dialysis patients.

PubMed

Gupta, Amit; Jain, Gaurav; Kaur, Manpreet; Jaryal, Ashok Kumar; Deepak, Kishore Kumar; Bhowmik, Dipankar; Agarwal, Sanjay Kumar

2016-04-01

Peritoneal dialysis patients have high cardiovascular morbidity and mortality. The underlying mechanism of cardiovascular dysfunction remains unclear. Large arterial stiffness in chronic kidney disease (CKD) patients leads to increase in pulse wave velocity (PWV) and decrease in baroreflex sensitivity (BRS). Impairment in baroreflex function could be attributed to the alteration in mechanical properties of large vessels due to arterial remodeling observed in these patients. The present study was designed to study the association of BRS and PWV in peritoneal dialysis (PD) patients. 42 CKD patients (21--without dialysis and 21--on PD) and 25 healthy controls were recruited in this study. BRS was determined by spontaneous sequence method. Short-term heart rate variability (HRV) and blood pressure variability (BPV) were assessed using power spectrum analysis of RR intervals and systolic blood pressure by time domain and frequency domain analysis. Arterial stiffness indices were assessed by carotid-femoral PWV using Sphygmocor Vx device (AtCor Medical, Australia). CKD patients had significantly high PWV and low BRS as compared to healthy controls. PWV had a significant negative correlation with BRS in CKD patients (Spearman r = -0.7049, P < 0.0001; BRS-Systolic BP). On subgroup analysis, PWV was higher with lower BRS in CKD patients on peritoneal dialysis (CKD-PD) as compared to those not on dialysis (CKD-ND). Negative relationship between PWV and BRS was found in both the groups. In addition, BRS was found to have a positive correlation with HRV in CKD patients as well as both the subgroups. Reduction in BRS is strongly associated with increase in PWV in PD patients. Large arterial stiffness probably explains this simultaneous impairment in baroreflex functioning and increase in pulse wave velocity observed in these patients. CKD patients are characterized by poor hemodynamic profile (low BRS, high PWV, and low HRV), and peritoneal dialysis patients had further

The effects of serum leptin levels on thrombocyte aggregation in peritoneal dialysis patients.

PubMed

Bakirdogen, Serkan; Eren, Necmi; Bek, Sibel Gokcay; Mehtap, Ozgur; Cekmen, Mustafa Baki

2016-01-01

Serum leptin levels of chronic kidney disease patients have been detected higher than normal population. The aim of this study was to investigate the effects of serum leptin levels on thrombocyte aggregation in peritoneal dialysis patients. Fourty three peritoneal dialysis patients were included in the study. Thrombocyte aggregation was calculated from the whole blood subsequently the effects of different concentrations of human recombinant leptin on thrombocyte aggregations were investigated. Four test cells were used for this process. While leptin was not added into the first test cell, increasing amounts of leptin was added into the second, third and fourth test cells to attain the concentrations of 25, 50 and 100 ng/ml respectively. Thrombocyte aggregation was inhibited by recombinant leptin in peritoneal dialysis patients. Thrombocyte aggregation mean values were found statistically significantly higher in first test cell when compared to leptin groups in peritoneal dialysis patients. For leptin groups we could not find any statistically significant differences for thrombocyte aggregation mean values between any of the groups. Further studies with larger number of peritoneal dialysis patients are required to prove the action of leptin on thrombocyte aggregation.

The effects of serum leptin levels on thrombocyte aggregation in peritoneal dialysis patients

PubMed Central

Bakirdogen, Serkan; Eren, Necmi; Bek, Sibel Gokcay; Mehtap, Ozgur; Cekmen, Mustafa Baki

2016-01-01

Objective: Serum leptin levels of chronic kidney disease patients have been detected higher than normal population. The aim of this study was to investigate the effects of serum leptin levels on thrombocyte aggregation in peritoneal dialysis patients. Methods: Fourty three peritoneal dialysis patients were included in the study. Thrombocyte aggregation was calculated from the whole blood subsequently the effects of different concentrations of human recombinant leptin on thrombocyte aggregations were investigated. Four test cells were used for this process. While leptin was not added into the first test cell, increasing amounts of leptin was added into the second, third and fourth test cells to attain the concentrations of 25, 50 and 100 ng/ml respectively. Results: Thrombocyte aggregation was inhibited by recombinant leptin in peritoneal dialysis patients. Thrombocyte aggregation mean values were found statistically significantly higher in first test cell when compared to leptin groups in peritoneal dialysis patients. For leptin groups we could not find any statistically significant differences for thrombocyte aggregation mean values between any of the groups. Conclusion: Further studies with larger number of peritoneal dialysis patients are required to prove the action of leptin on thrombocyte aggregation. PMID:28083046

Patient and Physician Views about Protocolized Dialysis Treatment in Randomized Trials and Clinical Care.

PubMed

Kraybill, Ashley; Dember, Laura M; Joffe, Steven; Karlawish, Jason; Ellenberg, Susan S; Madden, Vanessa; Halpern, Scott D

2016-01-01

Pragmatic trials comparing standard-of-care interventions may improve the quality of care for future patients, but raise ethical questions about limitations on decisional autonomy. We sought to understand how patients and physicians view and respond to these questions in the contexts of pragmatic trials and of usual clinical care. We conducted scenario-based, semi-structured interviews with 32 patients with end-stage renal disease (ESRD) receiving maintenance hemodialysis in outpatient dialysis units and with 24 nephrologists. Each participant was presented with two hypothetical scenarios in which a protocolized approach to hemodialysis treatment time was adopted for the entire dialysis unit as part of a clinical trial or a new clinical practice. A modified grounded theory analysis revealed three major themes: 1) the value of research, 2) the effect of protocolized care on patient and physician autonomy, and 3) information exchange between patients and physicians, including the mechanism of consent. Most patients and physicians were willing to relinquish decisional autonomy and were more willing to relinquish autonomy for research purposes than in clinical care. Patients' concerns towards clinical trials were tempered by their desires for certainty for a positive outcome and for physician validation. Patients tended to believe that being informed about research was more important than the actual mechanism of consent, and most were content with being able to opt out from participating. This qualitative study suggests the general acceptability of a pragmatic clinical trial comparing standard-of-care interventions that limits decisional autonomy for nephrologists and patients receiving hemodialysis. Future studies are needed to determine whether similar findings would emerge among other patients and providers considering other standard-of-care trials.

Frailty Screening Tools for Elderly Patients Incident to Dialysis.

PubMed

van Loon, Ismay N; Goto, Namiko A; Boereboom, Franciscus T J; Bots, Michiel L; Verhaar, Marianne C; Hamaker, Marije E

2017-09-07

A geriatric assessment is an appropriate method for identifying frail elderly patients. In CKD, it may contribute to optimize personalized care. However, a geriatric assessment is time consuming. The purpose of our study was to compare easy to apply frailty screening tools with the geriatric assessment in patients eligible for dialysis. A total of 123 patients on incident dialysis ≥65 years old were included <3 weeks before to ≤2 weeks after dialysis initiation, and all underwent a geriatric assessment. Patients with impairment in two or more geriatric domains on the geriatric assessment were considered frail. The diagnostic abilities of six frailty screening tools were compared with the geriatric assessment: the Fried Frailty Index, the Groningen Frailty Indicator, Geriatric8, the Identification of Seniors at Risk, the Hospital Safety Program, and the clinical judgment of the nephrologist. Outcome measures were sensitivity, specificity, positive predictive value, and negative predictive value. In total, 75% of patients were frail according to the geriatric assessment. Sensitivity of frailty screening tools ranged from 48% (Fried Frailty Index) to 88% (Geriatric8). The discriminating features of the clinical judgment were comparable with the other screening tools. The Identification of Seniors at Risk screening tool had the best discriminating abilities, with a sensitivity of 74%, a specificity of 80%, a positive predictive value of 91%, and a negative predictive value of 52%. The negative predictive value was poor for all tools, which means that almost one half of the patients screened as fit (nonfrail) had two or more geriatric impairments on the geriatric assessment. All frailty screening tools are able to detect geriatric impairment in elderly patients eligible for dialysis. However, all applied screening tools, including the judgment of the nephrologist, lack the discriminating abilities to adequately rule out frailty compared with a geriatric assessment

Effects of Ginger on Serum Lipids and Lipoproteins in Peritoneal Dialysis Patients: A Randomized Controlled Trial.

PubMed

Tabibi, Hadi; Imani, Hossein; Atabak, Shahnaz; Najafi, Iraj; Hedayati, Mehdi; Rahmani, Leila

2016-01-01

♦ In peritoneal dialysis (PD) patients, one of the major risk factors for cardiovascular disease is lipid abnormalities. This study was designed to investigate the effects of ginger supplementation on serum lipids and lipoproteins in PD patients. ♦ In this randomized, double-blind, placebo-controlled trial, 36 PD patients were randomly assigned to either the ginger or the placebo group. The patients in the ginger group received 1,000 mg ginger daily for 10 weeks, while the placebo group received corresponding placebos. At baseline and at the end of week 10, 7 mL of blood were obtained from each patient after a 12- to 14-hour fast, and serum concentrations of triglyceride, total cholesterol, low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C), and lipoprotein (a) [Lp (a)] were measured. ♦ Serum triglyceride concentration decreased significantly up to 15% in the ginger group at the end of week 10 compared with baseline (p < 0.01), and the reduction was significant in comparison with the placebo group (p < 0.05). There were no significant differences between the 2 groups in mean changes of serum total cholesterol, LDL-C, HDL-C, and Lp (a). ♦ This study indicates that daily administration of 1,000 mg ginger reduces serum triglyceride concentration, which is a risk factor for cardiovascular disease, in PD patients. Copyright © 2016 International Society for Peritoneal Dialysis.

The impact of travel time on geographic distribution of dialysis patients.

PubMed

Kashima, Saori; Matsumoto, Masatoshi; Ogawa, Takahiko; Eboshida, Akira; Takeuchi, Keisuke

2012-01-01

The geographic disparity of prevalence rates among dialysis patients is unclear. We evaluate the association between travel time to dialysis facilities and prevalence rates of dialysis patients living in 1,867 census areas of Hiroshima, Japan. Furthermore, we study the effects of geographic features (mainland or island) on the prevalence rates and assess if these effects modify the association between travel time and prevalence. The study subjects were all 7,374 people that were certified as the "renal disabled" by local governments in 2011. The travel time from each patient to the nearest available dialysis facility was calculated by incorporating both travel time and the capacity of all 98 facilities. The effect of travel time on the age- and sex-adjusted standard prevalence rate (SPR) and 95% confidence intervals (CIs) at each census area was evaluated in two-level Poisson regression models with 1,867 census areas (level 1) nested within 35 towns or cities (level 2). The results were adjusted for area-based parameters of socioeconomic status, urbanity, and land type. Furthermore, the SPR of dialysis patients was calculated in each specific subgroup of population for travel time, land type, and combination of land type and travel time. In the regression analysis, SPR decreased by 5.2% (95% CI: -7.9--2.3) per 10-min increase in travel time even after adjusting for potential confounders. The effect of travel time on prevalence was different in the mainland and island groups. There was no travel time-dependent SPR disparity on the islands. The SPR among remote residents (>30 min from facilities) in the mainland was lower (0.77, 95% CI: 0.71-0.85) than that of closer residents (≤ 30 min; 0.95, 95% CI: 0.92-0.97). The prevalence of dialysis patients was lower among remote residents. Geographic difficulties for commuting seem to decrease the prevalence rate.

Initiating Maintenance Dialysis Before Living Kidney Donor Transplantation When a Donor Candidate Evaluation Is Well Underway.

PubMed

Habbous, Steven; McArthur, Eric; Dixon, Stephanie N; McKenzie, Susan; Garcia-Ochoa, Carlos; Lam, Ngan N; Lentine, Krista L; Dipchand, Christine; Litchfield, Kenneth; Begen, Mehmet A; Sarma, Sisira; Garg, Amit X

2018-07-01

Preemptive kidney transplants result in better outcomes and patient experiences than transplantation after dialysis onset. It is unknown how often a person initiates maintenance dialysis before living kidney donor transplantation when their donor candidate evaluation is well underway. Using healthcare databases, we retrospectively studied 478 living donor kidney transplants from 2004 to 2014 across 5 transplant centers in Ontario, Canada, where the recipients were not receiving dialysis when their donor's evaluation was well underway. We also explored some factors associated with a higher likelihood of dialysis initiation before transplant. A total of 167 (35%) of 478 persons with kidney failure initiated dialysis in a median of 9.7 months (25th-75th percentile, 5.4-18.7 months) after their donor candidate began their evaluation and received dialysis for a median of 8.8 months (3.6-16.9 months) before kidney transplantation. The total cohort's dialysis cost was CAD $8.1 million, and 44 (26%) of 167 recipients initiated their dialysis urgently in hospital. The median total donor evaluation time (time from evaluation start to donation) was 10.6 months (6.4-21.6 months) for preemptive transplants and 22.4 months (13.1-38.7 months) for donors whose recipients started dialysis before transplant. Recipients were more likely to start dialysis if their donor was female, nonwhite, lived in a lower-income neighborhood, and if the transplant center received the recipient referral later. One third of persons initiated dialysis before receiving their living kidney donor transplant, despite their donor's evaluation being well underway. Future studies should consider whether some of these events can be prevented by addressing inappropriate delays to improve patient outcomes and reduce healthcare costs.

Dietary restrictions in dialysis patients: is there anything left to eat?

PubMed

Kalantar-Zadeh, Kamyar; Tortorici, Amanda R; Chen, Joline L T; Kamgar, Mohammad; Lau, Wei-Ling; Moradi, Hamid; Rhee, Connie M; Streja, Elani; Kovesdy, Csaba P

2015-01-01

A significant number of dietary restrictions are imposed traditionally and uniformly on maintenance dialysis patients, whereas there is very little data to support their benefits. Recent studies indicate that dietary restrictions of phosphorus may lead to worse survival and poorer nutritional status. Restricting dietary potassium may deprive dialysis patients of heart-healthy diets and lead to intake of more atherogenic diets. There is little data about the survival benefits of dietary sodium restriction, and limiting fluid intake may inherently lead to lower protein and calorie consumption, when in fact dialysis patients often need higher protein intake to prevent and correct protein-energy wasting. Restricting dietary carbohydrates in diabetic dialysis patients may not be beneficial in those with burnt-out diabetes. Dietary fat including omega-3 fatty acids may be important caloric sources and should not be restricted. Data to justify other dietary restrictions related to calcium, vitamins, and trace elements are scarce and often contradictory. The restriction of eating during hemodialysis treatment is likely another incorrect practice that may worsen hemodialysis induced hypoglycemia and nutritional derangements. We suggest careful relaxation of most dietary restrictions and adoption of a more balanced and individualized approach, thereby easing some of these overzealous restrictions that have not been proven to offer major advantages to patients and their outcomes and which may in fact worsen patients' quality of life and satisfaction. This manuscript critically reviews the current paradigms and practices of recommended dietary regimens in dialysis patients including those related to dietary protein, carbohydrate, fat, phosphorus, potassium, sodium, and calcium, and discusses the feasibility and implications of adherence to ardent dietary restrictions and future research. © 2015 Wiley Periodicals, Inc.

Trends in Acute Nonvariceal Upper Gastrointestinal Bleeding in Dialysis Patients

PubMed Central

Yang, Ju-Yeh; Lee, Tsung-Chun; Montez-Rath, Maria E.; Paik, Jane; Chertow, Glenn M.; Desai, Manisha

2012-01-01

Impaired kidney function is a risk factor for upper gastrointestinal (GI) bleeding, an event associated with poor outcomes. The burden of upper GI bleeding and its effect on patients with ESRD are not well described. Using data from the US Renal Data System, we quantified the rates of occurrence of and associated 30-day mortality from acute, nonvariceal upper GI bleeding in patients undergoing dialysis; we used medical claims and previously validated algorithms where available. Overall, 948,345 patients contributed 2,296,323 patient-years for study. The occurrence rates for upper GI bleeding were 57 and 328 episodes per 1000 person-years according to stringent and lenient definitions of acute, nonvariceal upper GI bleeding, respectively. Unadjusted occurrence rates remained flat (stringent) or increased (lenient) from 1997 to 2008; after adjustment for sociodemographic characteristics and comorbid conditions, however, we found a significant decline for both definitions (linear approximation, 2.7% and 1.5% per year, respectively; P<0.001). In more recent years, patients had higher hematocrit levels before upper GI bleeding episodes and were more likely to receive blood transfusions during an episode. Overall 30-day mortality was 11.8%, which declined significantly over time (relative declines of 2.3% or 2.8% per year for the stringent and lenient definitions, respectively). In summary, despite declining trends worldwide, crude rates of acute, nonvariceal upper GI bleeding among patients undergoing dialysis have not decreased in the past 10 years. Although 30-day mortality related to upper GI bleeding declined, perhaps reflecting improvements in medical care, the burden on the ESRD population remains substantial. PMID:22266666

Hypersensitivity reactions in patients receiving hemodialysis.

PubMed

Butani, Lavjay; Calogiuri, Gianfranco

2017-06-01

To describe hypersensitivity reactions in patients receiving maintenance hemodialysis. PubMed search of articles published during the past 30 years with an emphasis on publications in the past decade. Case reports and review articles describing hypersensitivity reactions in the context of hemodialysis. Pharmacologic agents are the most common identifiable cause of hypersensitivity reactions in patients receiving hemodialysis. These include iron, erythropoietin, and heparin, which can cause anaphylactic or pseudoallergic reactions, and topical antibiotics and anesthetics, which lead to delayed-type hypersensitivity reactions. Many hypersensitivity reactions are triggered by complement activation and increased bradykinin resulting from contact system activation, especially in the context of angiotensin-converting enzyme inhibitor use. Several alternative pharmacologic preparations and dialyzer membranes are available, such that once an etiology for the reaction is established, recurrences can be prevented without affecting the quality of care provided to patients. Although hypersensitivity reactions are uncommon in patients receiving hemodialysis, they can be life-threatening. Moreover, considering the large prevalence of the end-stage renal disease population, the implications of such reactions are enormous. Most reactions are pseudoallergic and not mediated by immunoglobulin E. The multiplicity of potential exposures and the complexity of the environment to which patients on dialysis are exposed make it challenging to identify the precise cause of these reactions. Great diligence is needed to investigate hypersensitivity reactions to avoid recurrence in this high-risk population. Copyright © 2017 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Patient and Physician Views about Protocolized Dialysis Treatment in Randomized Trials and Clinical Care

PubMed Central

Kraybill, Ashley; Dember, Laura M.; Joffe, Steven; Karlawish, Jason; Ellenberg, Susan S.; Madden, Vanessa; Halpern, Scott D.

2016-01-01

Background Pragmatic trials comparing standard-of-care interventions may improve the quality of care for future patients, but raise ethical questions about limitations on decisional autonomy. We sought to understand how patients and physicians view and respond to these questions in the contexts of pragmatic trials and of usual clinical care. Methods We conducted scenario-based, semi-structured interviews with 32 patients with end-stage renal disease (ESRD) receiving maintenance hemodialysis in outpatient dialysis units and with 24 nephrologists. Each participant was presented with two hypothetical scenarios in which a protocolized approach to hemodialysis treatment time was adopted for the entire dialysis unit as part of a clinical trial or a new clinical practice. Results A modified grounded theory analysis revealed three major themes: 1) the value of research, 2) the effect of protocolized care on patient and physician autonomy, and 3) information exchange between patients and physicians, including the mechanism of consent. Most patients and physicians were willing to relinquish decisional autonomy and were more willing to relinquish autonomy for research purposes than in clinical care. Patients’ concerns towards clinical trials were tempered by their desires for certainty for a positive outcome and for physician validation. Patients tended to believe that being informed about research was more important than the actual mechanism of consent, and most were content with being able to opt out from participating. Conclusions This qualitative study suggests the general acceptability of a pragmatic clinical trial comparing standard-of-care interventions that limits decisional autonomy for nephrologists and patients receiving hemodialysis. Future studies are needed to determine whether similar findings would emerge among other patients and providers considering other standard-of-care trials. PMID:27833931

Impacts on dialysis therapy.

PubMed

Passon, S; Uthoff, S; Jäckle-Meyer, I

1998-01-01

Improvement of clinical outcome of dialysis therapy is a task for everybody working in a dialysis unit. Here we consider dialysis conditions such as choice of treatment parameters and composition of dialysis fluid which may influence clinical outcome of dialysis therapy. Providing 'adequate' dialysis is the aim of the daily work of a dialysis nurse. Haemodialysis parameters with potential impact on dialysis adequacy are discussed with respect to quantification and optimisation. Every year, each patient comes in contact with 20,000 I dialysis fluid during HD treatment. The composition of the fluid, its physical and microbiological quality and their impact on clinical outcome are considered. The function of PD fluid is different from that of an HD fluid thus additional aspects have to be considered regarding its composition. Information is given how the composition and biocompatibility of PD solutions impact the dialysis therapy and how individual patient needs are considered.

A Palliative Approach to Dialysis Care: A Patient-Centered Transition to the End of Life

PubMed Central

Moss, Alvin H.; Cohen, Lewis M.; Fischer, Michael J.; Germain, Michael J.; Jassal, S. Vanita; Perl, Jeffrey; Weiner, Daniel E.; Mehrotra, Rajnish

2014-01-01

As the importance of providing patient-centered palliative care for patients with advanced illnesses gains attention, standard dialysis delivery may be inconsistent with the goals of care for many patients with ESRD. Many dialysis patients with life expectancy of <1 year may desire a palliative approach to dialysis care, which focuses on aligning patient treatment with patients’ informed preferences. This commentary elucidates what comprises a palliative approach to dialysis care and describes its potential and appropriate use. It also reviews the barriers to integrating such an approach into the current clinical paradigm of care and existing infrastructure and outlines system-level changes needed to accommodate such an approach. PMID:25104274

Epidemiology and mortality of liver abscess in end-stage renal disease dialysis patients: Taiwan national cohort study.

PubMed

Hong, Chon-Seng; Chung, Kun-Ming; Huang, Po-Chang; Wang, Jhi-Joung; Yang, Chun-Ming; Chu, Chin-Chen; Chio, Chung-Ching; Chang, Fu-Lin; Chien, Chih-Chiang

2014-01-01

To determine the incidence rates and mortality of liver abscess in ESRD patients on dialysis. Using Taiwan's National Health Insurance Research Database, we collected data from all ESRD patients who initiated dialysis between 2000 and 2006. Patients were followed until death, end of dialysis, or December 31, 2008. Predictors of liver abscess and mortality were identified using Cox models. Of the 53,249 incident dialysis patients identified, 447 were diagnosed as having liver abscesses during the follow-up period (224/100,000 person-years). The cumulative incidence rate of liver abscess was 0.3%, 1.1%, and 1.5% at 1 year, 5 years, and 7 years, respectively. Elderly patients and patients on peritoneal dialysis had higher incidence rates. The baseline comorbidities of diabetes mellitus, polycystic kidney disease, malignancy, chronic liver disease, biliary tract disease, or alcoholism predicted development of liver abscess. Overall in-hospital mortality was 10.1%. The incidence of liver abscess is high among ESRD dialysis patients. In addition to the well known risk factors of liver abscess, two other important risk factors, peritoneal dialysis and polycystic kidney disease, were found to predict liver abscess in ESRD dialysis patients.

Prospective safety study of bardoxolone methyl in patients with type 2 diabetes mellitus, end-stage renal disease and peritoneal dialysis.

PubMed

Warnock, David G; Hebbar, Sudarshan; Bargman, Joanne; Burkart, John; Davies, Simon; Finkelstein, Frederic O; Mehrotra, Rajnish; Ronco, Claudio; Teitelbaum, Isaac; Urakpo, Kingsley; Chertow, Glenn M

2012-01-01

Patients on peritoneal dialysis experience inflammation associated with advanced chronic kidney disease and the therapy itself. An important consequence of the inflammation may be acceleration of the rate of decline in residual renal function. The decline in residual renal function has been associated with an increased mortality for patients in this population. Bardoxolone methyl is a synthetic triterpenoid. To date, the effects of bardoxolone methyl on kidney function in humans have been studied in patients with type 2 diabetes mellitus. A large-scale event-driven study of bardoxolone methyl in patients with type 2 diabetes mellitus with stage 4 chronic kidney disease is underway. The safety of bardoxolone methyl has not been evaluated in patients with more advanced (stage 5) chronic kidney disease or patients on dialysis. This report describes a proposed double blind, prospective evaluation of bardoxolone methyl in patients with type 2 diabetes mellitus receiving peritoneal dialysis. In addition to assessing the safety of bardoxolone methyl in this population, the study will evaluate the effect of bardoxolone methyl on residual renal function over 6 months as compared to placebo. Copyright © 2012 S. Karger AG, Basel.

Religious involvement and health in dialysis patients in Saudi Arabia.

PubMed

Al Zaben, Faten; Khalifa, Doaa Ahmed; Sehlo, Mohammad Gamal; Al Shohaib, Saad; Binzaqr, Salma Awad; Badreg, Alae Magdi; Alsaadi, Rawan Ali; Koenig, Harold G

2015-04-01

Patients on hemodialysis experience considerable psychological and physical stress due to the changes brought on by chronic kidney disease. Religion is often turned to in order to cope with illness and may buffer some of these stresses associated with illness. We describe here the religious activities of dialysis patients in Saudi Arabia and determined demographic, psychosocial, and physical health correlates. We administered an in-person questionnaire to 310 dialysis patients (99.4 % Muslim) in Jeddah, Saudi Arabia, that included the Muslim Religiosity Scale, Structured Clinical Interview for Depression, Hamilton Depression Rating Scale, Global Assessment of Functioning scale, and other established measures of psychosocial and physical health. Bivariate and multivariate analyses identified characteristics of patients who were more religiously involved. Religious practices and intrinsic religious beliefs were widespread. Religious involvement was more common among those who were older, better educated, had higher incomes, and were married. Overall psychological functioning was better and social support higher among those who were more religious. The religious also had better physical functioning, better cognitive functioning, and were less likely to smoke, despite having more severe overall illness and being on dialysis for longer than less religious patients. Religious involvement is correlated with better overall psychological functioning, greater social support, better physical and cognitive functioning, better health behavior, and longer duration of dialysis. Whether religion leads to or is a result of better mental and physical health will need to be determined by future longitudinal studies and clinical trials.

Peritoneal Dialysis to Treat Patients with Acute Kidney Injury-The Saving Young Lives Experience in West Africa: Proceedings of the Saving Young Lives Session at the First International Conference of Dialysis in West Africa, Dakar, Senegal, December 2015.

PubMed

Abdou, Niang; Antwi, Sampson; Koffi, Laurence Adonis; Lalya, Francis; Adabayeri, Victoria May; Nyah, Norah; Palmer, Dennis; Brusselmans, Ariane; Cullis, Brett; Feehally, John; McCulloch, Mignon; Smoyer, William; Finkelstein, Fredric O

2017-01-01

In December 2015, as part of the First African Dialysis Conference organized in Dakar, Senegal, 5 physicians from West African countries who have participated in the Saving Young Lives Program reviewed their experiences establishing peritoneal dialysis (PD) programs to treat patients with acute kidney injury (AKI). Thus far, nearly 200 patients have received PD treatment in these countries. The interaction and discussion amongst the participants at the meeting was meaningful and informative. The presentations highlighted the creativity, conviction, and determination of the physicians in overcoming the various barriers and challenges they encountered to establish PD/AKI programs. Hopefully, these successes and the increased awareness of the importance of early diagnosis and treatment of AKI will inspire much needed support from government, hospital, and international organizations. Copyright © 2017 International Society for Peritoneal Dialysis.

A palliative approach to dialysis care: a patient-centered transition to the end of life.

PubMed

Grubbs, Vanessa; Moss, Alvin H; Cohen, Lewis M; Fischer, Michael J; Germain, Michael J; Jassal, S Vanita; Perl, Jeffrey; Weiner, Daniel E; Mehrotra, Rajnish

2014-12-05

As the importance of providing patient-centered palliative care for patients with advanced illnesses gains attention, standard dialysis delivery may be inconsistent with the goals of care for many patients with ESRD. Many dialysis patients with life expectancy of <1 year may desire a palliative approach to dialysis care, which focuses on aligning patient treatment with patients' informed preferences. This commentary elucidates what comprises a palliative approach to dialysis care and describes its potential and appropriate use. It also reviews the barriers to integrating such an approach into the current clinical paradigm of care and existing infrastructure and outlines system-level changes needed to accommodate such an approach. Copyright © 2014 by the American Society of Nephrology.

Differences in Prevalence of Muscle Wasting in Patients Receiving Peritoneal Dialysis per Dual-Energy X-Ray Absorptiometry Due to Variation in Guideline Definitions of Sarcopenia.

PubMed

Hung, Rachel; Wong, Bethany; Goldet, Gabrielle; Davenport, Andrew

2017-08-01

Muscle wasting is associated with increased risk for mortality. There is no agreed universal definition for muscle wasting (sarcopenia), and we wished to determine whether using different criteria altered the prevalence in patients treated by peritoneal dialysis. We measured lean body and appendicular lean mass indices in 325 outpatients by dual-energy x-ray absorptiometry, comparing muscle mass with that used to define muscle wasting (sarcopenia) by various clinical guideline publications. Lean body and appendicular lean mass indices did not differ by sex: female, 17.7 ± 4.6 kg/m 2 ; male, 17.4 ± 4.3; female, 6.9 (5.6-8.5) kg/m 2 ; male, 6.7 (5.3-8.3), respectively. Depending on the criteria, the prevalence of muscle wasting varied from 2.2%-31.3% for women and 25.1%-75.6% for men. Male patients were older (58.3 ± 16 vs 53.4 ± 15.7 years). Criteria based on cutoffs derived from young healthy patients gave the higher prevalence rates. The prevalence of muscle wasting was not associated with dialysis adequacy, estimated protein intake, duration of dialysis treatment, comorbidity, diabetes, or ethnicity. The prevalence of sarcopenic obesity was low (<5% females, 7% males). We found that the prevalence varied markedly depending on the cutoff criteria used to define muscle wasting. Very few patients had sarcopenic obesity. The higher prevalence for males requires further study but was not associated with dialysis treatment. Our study highlights the need for agreed criteria to define pathologic muscle wasting from that which is age associated to allow for interventional screening programs.

[Residual renal function and nutritional status in patients on continuous ambulatory peritoneal dialysis].

PubMed

Jovanović, Natasa; Lausević, Mirjana; Stojimirović, Biljana

2005-01-01

During the last years, an increasing number of patients with end-stage renal failure caused by various underlying diseases, all over the world, is treated by renal replacement therapy. NUTRITIONAL STATUS: Malnutrition is often found in patients affected by renal failure; it is caused by reduced intake of nutritional substances due to anorexia and dietary restrictions hormonal and metabolic disorders, comorbid conditions and loss of proteins, amino-acids, and vitamins during the dialysis procedure itself. Nutritional status significantly affects the outcome of patients on chronic dialysis treatment. Recent epiodemiological trials have proved that survival on chronic continuous ambulatory peritoneal dialysis program depends more on residual renal function (RRF) than on peritoneal clearances of urea and creatinine. The aim of the study was to analyze the influence of RRF on common biochemical and anthropometric markers of nutrition in 32 patients with end-stage renal failure with various underlying diseases during the first 6 months on continuous ambulatory peritoneal dialysis (CAPD). The mean residual creatinine clearance was 8,3 ml/min and the mean RRF was 16,24 l/week in our patients at the beginning of the chronic peritoneal dialysis treatment. During the follow-up, the RRF slightly decreased, while the nutritional status of patients significantly improved. Gender and age, as well as the leading disease and peritonitis didn't influence the RRF during the first 6 months of CAPD treatment. We found several positive correlations between RRF and laboratory and anthropometric markers of nutrition during the follow-up, proving the positive influence of RRF on nutritional status of patients on chronic peritoneal dialysis.

Histological Spectrum of Idiopathic Noncirrhotic Portal Hypertension in Liver Biopsies From Dialysis Patients.

PubMed

Lee, Hwajeong; Ainechi, Sanaz; Singh, Mandeep; Ells, Peter F; Sheehan, Christine E; Lin, Jingmei

2015-09-01

Liver biopsy is performed for various indications in dialysis patients. Being a less-common subset, the hepatic pathology in renal dialysis is not well documented. Idiopathic noncirrhotic portal hypertension (INCPH) is a clinical entity associated with unexplained portal hypertension and/or a spectrum of histopathological vascular changes in the liver. After encountering INCPH and vascular changes of INCPH in 2 renal dialysis patients, we sought to further investigate this noteworthy association. A random search for patients on hemodialysis or peritoneal dialysis with liver biopsy was performed. Hematoxylin and eosin, reticulin, trichrome, and CK7 stains were performed on formalin-fixed, paraffin-embedded tissue sections. Histopathological features were reviewed, and the results were correlated with clinical findings. In all, 13 liver biopsies were retrieved. The mean cumulative duration of dialysis was 50 months (range = 17 months to 11 years). All patients had multiple comorbidities. Indications for biopsy were a combination of abnormal liver function tests (6), portal hypertension (4), ascites (3), and possible cirrhosis (3). Two patients with portal hypertension underwent multiple liver biopsies for diagnostic purposes. All (100%) biopsies showed some histological features of INCPH, including narrowed portal venous lumen (9), increased portal vascular channels (8), shunt vessels (3), dilated sinusoids (9), regenerative nodule (5), and features of venous outflow obstruction (3). No cirrhosis was identified. Liver biopsies from patients on dialysis demonstrate histopathological vascular changes of INCPH. Some (31%) patients present with portal hypertension without cirrhosis. The histological changes may be reflective of underlying risk factors for INCPH in this group. © The Author(s) 2015.

Dietary Restrictions in Dialysis Patients: Is There Anything Left to Eat?

PubMed Central

Kalantar-Zadeh, Kamyar; Brown, Amanda; Chen, Joline L. T.; Kamgar, Mohammad; Lau, Wei-Ling; Moradi, Hamid; Rhee, Connie M.; Streja, Elani; Kovesdy, Csaba P.

2015-01-01

A significant number of dietary restrictions are imposed traditionally and uniformly on maintenance dialysis patients, whereas there is very little data to support their benefits. Recent studies indicate that dietary restrictions of phosphorus may lead to worse survival and poorer nutritional status. Restricting dietary potassium may deprive dialysis patients of heart-healthy diets and lead to intake of more atherogenic diets. There is little data about the survival benefits of dietary sodium restriction, and limiting fluid intake may inherently lead to lower protein and calorie consumption, when in fact dialysis patients often need higher protein intake to prevent and correct protein-energy wasting. Restricting dietary carbohydrates in diabetic dialysis patients may not be beneficial in those with burnt-out diabetes. Dietary fat including omega-3 fatty acids may be important caloric sources and should not be restricted. Data to justify other dietary restrictions related to calcium, vitamins and trace elements are scarce and often contradictory. The restriction of eating during hemodialysis treatment is likely another incorrect practice that may worsen hemodialysis induced hypoglycemia and nutritional derangements. We suggest careful relaxation of most dietary restrictions and adoption of a more balanced and individualized approach, thereby easing some of these overzealous restrictions that have not been proven to offer major advantages to patients and their outcomes and which may in fact worsen patients’ quality of life and satisfaction. This manuscript critically reviews the current paradigms and practices of recommended dietary regimens in dialysis patients including those related to dietary protein, carbohydrate, fat, phosphorus, potassium, sodium, and calcium, and discusses the feasibility and implications of adherence to ardent dietary restrictions. PMID:25649719

[Dialysis dose, nutrition and growth among pediatric patients on peritoneal dialysis].

PubMed

Cano, Francisco; Azócar, Marta; Marín, Verónica; Rodríguez, Eugenio; Delucchi, Angela; Ratner, Rinat; Cavada, Gabriel

2005-12-01

Stunting is common among pediatric patients on peritoneal dialysis. To establish the best profile for urea kinetic variables associated to growth in children on chronic peritoneal dialysis (PD). Twenty patients, aged 1 month to 14 years, 13 males, were followed for 6-12 months, with monthly measurements of weight/age and height/age Z score; plasma creatinine, BUN, protein and albumin and urine and dialysate urea nitrogen, creatinine, protein and albumin. Minimum total Kt/V was 2.1. Dialysis dose (Kt/V), Protein Equivalent of Urea Nitrogen Appearance (PNA), Protein Catabolic Rate (PCR) and Nitrogen Balance (NB) were calculated. To identify the variable(s) associated to growth, the Tree Classification Model (CART) Enterprise Miner 8.1 was applied. Mean total/residual Kt/V: 3.4+/-1.3/1.69+/-1.27; Daily Protein Intake (DPI) was 3.25+/-1.27 g/kg/day. nPNA, PCR and NB were 1.37+/-0.44, 0.84+/-0.33 and 1.86+/-1.25 g/kg/day, respectively. Mean height/age Z score was -2.3+/-1.19. Eleven patients showed a positive height/age delta Z (mean 0.55+/-0.38) and nine showed a negative growth (mean -0.50+/-0.42). The main variable explaining the positive growth was a Nitrogen Balance between 0.54 and 2.37 g/kg/day, mean 1.55+/-0.21 (p <0.001). The second associated variable to growth was a residual Kt/V between 0.43 and 4.6 (2.02+/-0.49) (p <0.05). Kt/V and nPNA showed a significant correlation, but no correlation could be found between Kt/V and NB. Nitrogen Balance was the main variable associated to growth in pediatric PD, with values between 0.53 to 2.38 g/kg/day. The second variable was a residual Kt/V between 0.43 and 4.6. Therapy should be reassessed with NB values less than 0.54 or above 2.37 g/kg/day.

Survival of patients treated for end-stage renal disease by dialysis and transplantation.

PubMed Central

Higgins, M. R.; Grace, M.; Dossetor, J. B.

1977-01-01

The results of treatment in 213 patients with end-stage renal disease who underwent hemodialysis, peritoneal dialysis or transplantation, or a combination, between 1962 and 1975 were analysed. Comparison by censored survival analysis showed significantly better (P less than 0.01) patient survival with the integrated therapy of dialysis and transplantation than with either form of dialysis alone. There was no significant difference in survival of males and females but survival at the extremes of age was poorer. Analysis of survival by major cause of renal failure indicated best survival in patients with congenital renal disease. Graft and patient survival rates at 1 year after the first transplantation were 42% and 69%. The major cause of death in this series was vascular disease but infection was responsible for 50% of deaths after transplantation. While integration of dialysis with transplantation produces best patient survival, this course is possible only when sufficient cadaver kidneys are available. PMID:334354

Tailoring dialysis and resuming low-protein diets may favor chronic dialysis discontinuation: report on three cases.

PubMed

Piccoli, Giorgina Barbara; Guzzo, Gabriella; Vigotti, Federica Neve; Capizzi, Irene; Clari, Roberta; Scognamiglio, Stefania; Consiglio, Valentina; Aroasio, Emiliano; Gonella, Silvana; Veltri, Andrea; Avagnina, Paolo

2014-07-01

Renal function recovery (RFR), defined as the discontinuation of dialysis after 3 months of replacement therapy, is reported in about 1% of chronic dialysis patients. The role of personalized, intensive dialysis schedules and of resuming low-protein diets has not been studied to date. This report describes three patients with RFR who were recently treated at a new dialysis unit set up to offer intensive hemodialysis. All three patients were females, aged 73, 75, and 78 years. Kidney disease included vascular-cholesterol emboli, diabetic nephropathy and vascular and dysmetabolic disease. At time of RFR, the patients had been dialysis-dependent from 3 months to 1 year. Dialysis was started with different schedules and was progressively discontinued with a "decremental" policy, progressively decreasing number and duration of the sessions. A moderately restricted low-protein diet (proteins 0.6 g/kg/day) was started immediately after dialysis discontinuation. The most recent update showed that two patients are well off dialysis for 5 and 6 months; the diabetic patient died (sudden death) 3 months after dialysis discontinuation. Within the limits of small numbers, our case series may suggest a role for personalized dialysis treatments and for including low-protein diets in the therapy, in enhancing long-term RFR in elderly dialysis patients. © 2014 International Society for Hemodialysis.

Additional benefit of dietitian involvement in dialysis staffs-led diet education on uncontrolled hyperphosphatemia in hemodialysis patients.

PubMed

Tsai, Wan-Chuan; Yang, Ju-Yeh; Luan, Chia-Chin; Wang, Yuh-Jiun; Lai, Yu-Chuan; Liu, Lie-Chuan; Peng, Yu-Sen

2016-10-01

Sustained adherence to dietary phosphorus (P) restriction recommendations among hemodialysis patients is questionable. The aim of this study was to evaluate the effectiveness of additional diet education delivered by a dietitian on the control of hyperphosphatemia. We conducted an 8-month prospective observational study in hemodialysis patients who had uncontrolled hyperphosphatemia. In the first half of the study (experimental) period, the dialysis nurses and physicians provided the routine dietetic education with the control group (n = 31), while the experimental group (n = 30) received the routine dietetic education plus an additional diet education delivered by dietitians. Both groups received the routine dietetic education in the rest of the study period to test whether the improvement of serum P level was sustained. The primary outcomes were changes in serum P level. At baseline, there was no significant difference in serum P levels between groups (P = 0.27). In the experimental period, monthly serum P levels decreased significantly in both groups (P < 0.001) and the magnitudes of reduction were 1.81 ± 1.46 and 0.94 ± 1.33 mg/dL in the experimental and control groups, respectively (P = 0.02), at the end. The experimental group maintained such improvement for one more month (P = 0.02), but faded out over time. Renal diet education guided either by dietitians plus dialysis staffs or dialysis staffs alone reduces serum P level and dietitian-guided diet education provides an additional benefit on controlling hyperphosphatemia in hemodialysis patients.

Association Between 25-Hydroxyvitamin D Level and Inflammatory and Nutritional Factors in Hemodialysis and Peritoneal dialysis Patients in Qom, Iran.

PubMed

Mirchi, Elham; Saghafi, Hossein; Gharehbeglou, Mohammad; Aghaali, Mohammad; Rezaian, Zahra; Ghaviahd, Masoomeh

2016-07-01

This study aimed to evaluate the prevalence of vitamin D inadequacy in patients receiving maintenance hemodialysis and peritoneal dialysis (PD) and its association with inflammatory and nutritional factors. A total of 176 hemodialysis and 32 PD patients participated in the study. Serum levels of 25-hydroxyvitamin D, albumin, parathyroid hormone, calcium, phosphorus, high-sensitivity C-reactive protein (HSCRP), and neutrophil-lymphocyte ratio (NLR) were measured. Data on body mass index were also collected. Stepwise multiple logistic regression analysis was used to identify predictors for 25-hydroxyvitamin D deficiency and its relationship with the nutritional and inflammatory factors. No significant association was found between 25-hydroxyvitamin D and age, body mass index, serum calcium, serum phosphorus, parathyroid hormone, serum albumin, dialysis quality, and duration of dialysis; while NLR and HSCRP were significantly associated with 25-hydroxyvitamin D in the hemodialysis patients only (P < .001 and P = .001, respectively). A positive correlation was found between NLR and HSCRP in both hemodialysis and PD patients. (r = 0.817; P < .001). This association was confirmed between an NLR greater than 3 and an HSCRP level greater than 3. Vitamin D deficiency was highly prevalent in our dialysis patients, and inadequate level of vitamin D was associated with inflammatory factors such as HSCRP and NLR in both hemodialysis and PD patients. An easy and inexpensive test of an NLR greater than 3 could be used as a measure of inflammation instead of HSCRP in both PD and hemodialysis patients.

Epidemiology and Mortality of Liver Abscess in End-Stage Renal Disease Dialysis Patients: Taiwan National Cohort Study

PubMed Central

Huang, Po-Chang; Wang, Jhi-Joung; Yang, Chun-Ming; Chu, Chin-Chen; Chio, Chung-Ching; Chang, Fu-Lin; Chien, Chih-Chiang

2014-01-01

Background and Objectives To determine the incidence rates and mortality of liver abscess in ESRD patients on dialysis. Design, Setting, Participants, & Measurements Using Taiwan’s National Health Insurance Research Database, we collected data from all ESRD patients who initiated dialysis between 2000 and 2006. Patients were followed until death, end of dialysis, or December 31, 2008. Predictors of liver abscess and mortality were identified using Cox models. Results Of the 53,249 incident dialysis patients identified, 447 were diagnosed as having liver abscesses during the follow-up period (224/100,000 person-years). The cumulative incidence rate of liver abscess was 0.3%, 1.1%, and 1.5% at 1 year, 5 years, and 7 years, respectively. Elderly patients and patients on peritoneal dialysis had higher incidence rates. The baseline comorbidities of diabetes mellitus, polycystic kidney disease, malignancy, chronic liver disease, biliary tract disease, or alcoholism predicted development of liver abscess. Overall in-hospital mortality was 10.1%. Conclusions The incidence of liver abscess is high among ESRD dialysis patients. In addition to the well known risk factors of liver abscess, two other important risk factors, peritoneal dialysis and polycystic kidney disease, were found to predict liver abscess in ESRD dialysis patients. PMID:24551077

Relationship between Fetuin A, Vascular Calcification and Fracture Risk in Dialysis Patients

PubMed Central

Chen, Hung Yuan; Chiu, Yen Ling; Hsu, Shih Ping; Pai, Mei Fen; Yang, Ju Yeh; Peng, Yu Sen

2016-01-01

Background Fractures are a common morbidity that lead to worse outcomes in dialysis patients. Fetuin A inhibits vascular calcification (VC), potentially promotes bone mineralization and its level positively correlates with bone mineral density in the general population. On the other hand, the presence of VC is associated with low bone volume in dialysis patients. Whether the fetuin A level and VC can predict the occurrence of fractures in dialysis patients remains unknown. Methods We performed this prospective, observational cohort study including 685 dialysis patients (629 hemodialysis and 56 peritoneal dialysis) from a single center in Taiwan for a median follow-up period of 3.4 years. The baseline fetuin A level and status of presence of aortic arch calcification (VC) and incidence of major fractures (hip, pelvis, humerus, proximal forearm, lower leg or vertebrae) were assessed using adjusted Cox proportional hazards models, recursive partitioning analysis and competing risk models. Results Overall, 177 of the patients had major fractures. The incidence rate of major fractures was 3.29 per 100 person-years. In adjusted analyses, the patients with higher baseline fetuin A levels had a lower incidence of fractures (adjusted hazard ratio (HR), 0.3; 95% CI, 0.18‒0.5, fetuin A tertile 3 vs. tertile 1 and HR, 0.52; 95% CI, 0.34‒0.78, tertile 2 vs. tertile 1). The presence of aortic arch calcification (VC) independently predicted the occurrence of fractures (adjusted HR, 1.95; 95% CI, 1.34‒2.84) as well. When accounting for death as an event in competing risk models, the patients with higher baseline fetuin A levels remained to have a lower incidence of fractures (SHR, 0.31; 95% CI, 0.17‒0.56, fetuin A tertile 3 vs. tertile 1 and 0.51; 95% CI, 0.32‒0.81, tertile 2 vs. tertile 1). Interpretations Lower baseline fetuin A levels and the presence of VC were independently linked to higher risk of incident fractures in prevalent dialysis patients. PMID:27398932

[Methodological approach to designing a telecare system for pre-dialysis and peritoneal dialysis patients].

PubMed

Calvillo-Arbizu, Jorge; Roa-Romero, Laura M; Milán-Martín, José A; Aresté-Fosalba, Nuria; Tornero-Molina, Fernando; Macía-Heras, Manuel; Vega-Díaz, Nicanor

2014-01-01

A major obstacle that hinders the implementation of technological solutions in healthcare is the rejection of developed systems by users (healthcare professionals and patients), who consider that they do not adapt to their real needs. (1) To design technological architecture for the telecare of nephrological patients by applying a methodology that prioritises the involvement of users (professionals and patients) throughout the design and development process; (2) to show how users' needs can be determined and addressed by means of technology, increasing the acceptance level of the final systems. In order to determine the main current needs in Nephrology, a group of Spanish Nephrology Services was involved. Needs were recorded through semi-structured interviews with the medical team and questionnaires for professionals and patients. A set of requirements were garnered from professionals and patients. In parallel, the group of biomedical engineers identified requirements for patient telecare from a technological perspective. All of these requirements drove the design of modular architecture for the telecare of peritoneal dialysis and pre-dialysis patients. This work shows how it is possible to involve users in the whole process of design and development of a system. The result of this work is the design of adaptable modular architecture for the telecare of nephrological patients and it addresses the preferences and needs of patient and professional users consulted.

[Technological advances and micro-inflammation in dialysis patients].

PubMed

Ferro, Giuseppe; Ravaglia, Fiammetta; Ferrari, Elisa; Romoli, Elena; Michelassi, Stefano; Caiani, David; Pizzarelli, Francesco

2015-01-01

As currently performed, on line hemodiafiltration reduces, but does not normalize, the micro-inflammation of uremic patients. Recent technological advances make it possible to further reduce the inflammation connected to the dialysis treatment. 
Short bacterial DNA fragments are pro-inflammatory and can be detected in the dialysis fluids. However, their determination is not currently within normal controls of the quality of the dialysate. The scenario may change once the analysis of these fragments yields reliable, inexpensive, quick and easy to evaluate the results. At variance with standard bicarbonate dialysate, Citrate dialysate induces far less inflammation both for the well-known anti-inflammatory effect of such buffer and also because it is completely acetate free, e.g. a definitely pro-inflammatory buffer. However, the extensive use of citrate dialysate in chronic dialysis is prevented because of concerns about its potential calcium lowering effect. In our view, high convective exchange on line hemodiafiltration performed with dialysate, whose sterility and a-pirogenicity is guaranteed by increasingly sophisticated controls and with citrate buffer whose safety is certified, can serve as the gold standard of dialysis treatments in future.

Comparison of three chronic dialysis models.

PubMed

Peng, W X; Guo, Q Y; Liu, S M; Liu, C Z; Lindholm, B; Wang, T

2000-01-01

The chronic peritoneal dialysis model is important for understanding the pathophysiology of peritoneal transport and for studying biocompatibility of peritoneal dialysis solutions. In this study, we compared three different chronic peritoneal dialysis models. A peritoneal catheter was placed in 23 male Sprague-Dawley rats, 12 of which had an intact omentum (model 1) and 11 of which received an omentectomy (model 2). Seven other rats, without a catheter, received a daily intraperitoneal injection (model 3). Each rat received a daily infusion of 25 mL of 3.86% glucose dialysis solution either through the catheter (models 1 and 2) or through injection (model 3) for 4 weeks. Then, a 4-hour dwell study using 3.86% glucose solution with an intraperitoneal volume marker and frequent dialysate and blood sampling was performed in each rat. The intraperitoneal volume was significantly lower in all the dialysis groups as compared to a control group (n = 6) in which the rats had no chronic dialysate exposure. The peritoneal fluid absorption rate, as well as the direct lymphatic absorption rate, was significantly higher in the three dialysis groups as compared to the control group. In general, no significant differences were seen in any of the parameters among the three dialysis models. Owing to catheter obstruction, three rats in model 1 and four rats in model 2 were lost during dialysis. Histological examination showed no significant differences among the three dialysis groups. Our results suggest that omentectomy may not be necessary in the chronic peritoneal dialysis model when using dialysate infusion and no drainage. Based on the present study, we think that perhaps model 1 may be the method of choice to test new peritoneal dialysis solutions. However, owing to its simplicity, model 3 could also be used if great care is taken to avoid puncturing the intestine or injecting into the abdominal wall.

Recent Progress of Bypass Surgery to the Dialysis-Dependent Patients with Critical Limb Ischemia

PubMed Central

Azuma, Nobuyoshi; Kikuchi, Shinsuke; Okuda, Hiroko; Miyake, Keisuke; Koya, Atsuhiro

2017-01-01

According to expansion of dialysis-dependent population, more than half of patients with critical ischemic limbs are dialysis-dependent in Japan. Although patients with end-staged renal disease are well-known as poor life prognosis, well-managed dialysis patients in Japan can survive much longer compared to dialysis patients in the United States and Europe. Therefore, some dialysis patients can enjoy the long-term benefits of bypass surgery. To decide the indication of bypass surgery, patient’s general condition, nutrition status, and vein availability are more important rather than arterial disease anatomy. Ultrasound guided nerve block anesthesia blocking both sciatic and femoral nerve is contributing greatly to quick postoperative recovery of high risk patients. Preoperative ultrasound examination also contribute to not only vein mapping but also find out the graftable segment of artery. The selection of distal target should be decided based on the degree of arterial disease (luminal surface as well as wall calcification), and arterial run-off. Several tips regarding anastomosis to heavily calcified artery have been established including how to create bloodless operative field without arterial clamps. Adequate wound management after bypass surgery is also important. Detection of deep infection such as osteomyelitis and the adequate treatment may avoid major amputation of salvageable limbs. In the era of endovascular treatment, the evidences guiding how to select dialysis patients suitable for bypass surgery are awaiting. (This is a translation of Jpn J Vasc Surg 2017; 26: 33–39.) PMID:29147171

Association of cinacalcet adherence and costs in patients on dialysis.

PubMed

Lee, Andrew; Song, Xue; Khan, Irfan; Belozeroff, Vasily; Goodman, William; Fulcher, Nicole; Diakun, David

2011-01-01

In addition to negative impacts on clinical effectiveness in treating secondary hyperparathyroidism, low adherence to cinacalcet may have negative impacts on healthcare costs. This study assessed the relationship between medication adherence and healthcare costs among US patients on dialysis given cinacalcet to manage secondary hyperparathyroidism. Retrospective cohort study of patients who were receiving dialysis with an initial cinacalcet prescription between January 2004 and April 2010 and who survived ≥12 months. Longitudinal, integrated medical, and pharmacy claims data from the MarketScan? database were used to calculate medication possession ratios (MPR) over 12 months and to examine the association of adherence with inpatient, outpatient, emergency room, outpatient medication, and total costs while controlling for patient characteristics, co-morbid medical conditions, and concomitant medication MPR in a multivariate regression model. Patients were dichotomized as adherent (<180 days refill gap) or non-adherent (≥180 day refill gap). Adherent patients were further dichotomized as low adherent (<0.8 MPR) and high adherent (≥0.8 MPR). The final study cohort included 4923 patients. After 12 months, 46% were non-adherent, 27% were low adherent, and 28% were high adherent. Greater cinacalcet adherence was associated with significantly lower inpatient costs with cost-savings of a greater magnitude than the increased medication costs. This study demonstrated that low adherence to cinacalcet, which may be associated with undesirable clinical and health-economic outcomes, is common. Despite limitations inherent in retrospective studies of claims databases, such as unobserved confounding, non-discrimination between prescription fill and actual use, and not knowing the reasons for non-adherence, these results suggest that inpatient cost savings of $8899, more than offset higher medication costs of $5858 associated with increased cinacalcet adherence.

Staphylococcus-Infected Tunneled Dialysis Catheters: Is Over-the-Wire Exchange an Appropriate Management Option?

DOE Office of Scientific and Technical Information (OSTI.GOV)

Langer, Jessica M.; Cohen, Raphael M.; Berns, Jeffrey S.

Purpose: Over-the-wire exchange of tunneled dialysis catheters is the standard of care per K/DOQI guidelines for treating catheter-related bacteremia. However, Gram-positive bacteremia, specifically with staphylococcus species, may compromise over-the-wire exchange due to certain biological properties. This study addressed the effectiveness of over-the-wire exchange of staphylococcus-infected tunneled dialysis catheters compared with non-staphylococcus-infected tunneled dialysis catheters. Methods: Patients who received over-the-wire exchange of their tunneled dialysis catheter due to documented or suspected bacteremia were identified from a QA database. Study patients (n = 61) had positive cultures for Staphylococcus aureus, Staphylococcus epidermidis, or coagulase-negative staphylococcus not otherwise specified. Control patients (n =more » 35) received over-the-wire exchange of their tunneled dialysis catheter due to infection with any organism besides staphylococcus. Overall catheter survival and catheter survival among staphylococcal species were assessed. Results: There was no difference in tunneled dialysis catheter survival between study and control groups (P = 0.46). Median survival time was 96 days for study catheters and 51 days for controls; survival curves were closely superimposed. There also was no difference among the three staphylococcal groups in terms of catheter survival (P = 0.31). The median time until catheter removal was 143 days for SE, 67 days for CNS, and 88 days for SA-infected catheters. Conclusions: There is no significant difference in tunneled dialysis catheter survival between over-the-wire exchange of staphylococcus-infected tunneled dialysis catheters and those infected with other organisms.« less

Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease